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.