Application and Proposal

Medical Student and Intern application for membership of MDA National Limited and proposal for professional indemnity insurance.

Thank you for your application. By completing this form, you are applying for Membership of MDA National Limited (MDA National) ABN 67 055 801 771 and a Professional Indemnity Insurance Policy underwritten by MDA National Insurance Pty Limited (MDA National Insurance) ABN 56 058 271 417, AFS Licence No. 238073. Please ensure you read the Important Notice overleaf before completing this form. Your Membership and Policy will commence upon receipt and acceptance of your Application and Proposal.

In this Application and Proposal form “we” “our” and “us” means MDA National and/or MDA National Insurance and “you” and “your” means the person seeking Membership and insurance. It is important that you ensure that this application and insurance proposal is accurate and complete. The information requested in this form is used by us for the purpose of considering your Membership and deciding whether or not to insure you and, if so, on what terms. If there is insufficient room on the application, please provide your answer on a separate attachment. Failure to disclose material information relevant to our decision to accept your Membership and the terms of insurance could invalidate the Membership and insurance contract. If you have any doubt as to whether any information is relevant, it should be disclosed.

Personal details

*Given name(s)

*Surname

*Gender

*Date of birth

*Primary email

I would like MDA National to send me all documents relating to my insurance policy and membership via email to the address provided by me

*Address

Address Not Found?

Country

*Address line 1

Address line 2

Address line 3

*Suburb

*State/Territory

*Postcode

*Mobile number

Medical qualifications, graduation and internship

Your category of cover will be based on the year and period of your graduation. Please read the important information regarding the applicable categories.

*When did you commence your medical degree?

*Medical School/University

Please specify

*Qualification

Please specify

*Graduation Year

*Policy Commencement Date (please select today's date to ensure you have adequate cover)

History — including indemnity, claims, complaints, investigations and proceedings

*Have you ever had any claims or complaints made against you arising from your provision of healthcare services, or are you aware of any circumstances which may give rise to a claim or complaint against you? No Yes

*Have you ever been the subject of any investigation, complaint, disciplinary or other proceeding, including but not limited to your medical studies or practice of medicine, your health or fitness to practice, your conduct as a student or medical practitioner? This includes proceedings by a University, registration board or any other academic or professional body. No Yes

*Have you ever been arrested or had criminal charges made against you in any jurisdiction whether or not the arrest or charge relates to your provision of healthcare services? For the purposes of this question, please disregard traffic or minor motor vehicle licensing offences. No Yes

Because you have answered YES to any questions in this section, you will need to provide us with more information. One of our team will contact you at a later time to discuss.

Declaration and acceptance

Please read the Important Notice before submitting your application

Application for Membership and Insurance

I wish to apply for Membership of MDA National Limited and a Professional Indemnity Insurance Policy underwritten by MDA National Insurance. If my Membership application is accepted I agree to be bound by the Constitution of MDA National and I undertake to contribute to the assets of MDA National, such amount as may be required, up to $10, if MDA National is wound up while I am a Member or within one year afterwards.

By submitting this form I declare that:

1. I agree to be bound by the terms and conditions of the policy.

2. I have read and understand the important notice and contents of this proposal and acknowledge that the information included in this form is accurate and complete.

3. I understand my duty of disclosure exists until the contract of insurance is entered into and that I have continuing obligation to inform MDA National Insurance of any material alteration of the risk during the period of insurance including any material change in the nature of the services provided by me.

Authorisation and consent

4. I consent to MDA National and MDA National Insurance and any companies, firms or individuals who assist them in providing services including but not limited to reinsurers, medical specialists, actuaries, accountants, legal advisers and IT contractors collecting, holding, using, disclosing and managing the personal information I provide, in accordance with the MDA National group privacy policy.

By checking this box, I have accepted and agree to the above terms

Medical Student