Quote Request Form

Please complete all fields and submit the form to us to receive a quote. We may contact you if we require further information before providing you with a quotation.

Your Personal Details & Indemnity Requirements

Name:
Phone Number:
Best time to call (between 8.30am to 8pm AEST):
Email Address:
Postal Address:
Suburb:
State:
Postcode:
Qualifications:
Year Graduated:
Specialty:
Policy Start Date:
Your Retroactive Requirements
Your policy will only respond to matters which result from your practice on or after the retroactive date. The retroactive date will therefore determine how much of your prior practice is covered under your policy. In answering this question, you may need to review your prior indemnity arrangements to determine your retroactive date. It is important for you to be aware that if you do not have sufficient retroactive cover, you may have to fund a claim or investigation personally, including any settlement or award and all associated costs.
Do you require retroactive cover?: YesNoNot sure, please contact me
Retroactive date required:

Your Current Situation

Please select the description that best describes your current situation:
I graduated within the last 2 to 5 years and work primarily as an employer indemnified doctor in a public hospital I graduated more than 5 years ago but am still completing an initial specialist training program with an accredited Medical College I graduated more than 5 years ago and work only as an employer indemnified doctor in a public hospital I work in a private practice and generate approximately $ billings for which I am required to arrange my own medical indemnity (please enter numerals only)
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