Quote Request Form
 

Personal Details

Please enter a value for Title
Please enter a value for First Name
Please enter a value for Surname
Please select a value for Gender
Please enter a value for Email
Please select a value for Date of Birth
According to our records, you are already a Member of MDA National and therefore you are unable to proceed with this online quotation request. Please refer to our Member Online Services to request a policy amendment, download a Certificate of Currency or view your policy history.For more information please contact our Member Services team on 1800 011 255 or email peaceofmind@mdanational.com.au

Your Contact Details

Please enter either a mobile, home or work phone number
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Please enter a value for Correspondence Address
Please enter a value for Address line 1
Please enter a value for Suburb
Please enter a value for State
Please enter a value for Postcode

Practice Details

Please select a Date
Please note MDA National’s policies run from 01 July to 30 June. As such, please select either today’s date or a future date as our policy start date. You are able to include cover for any practice prior to this date by completing the retroactive cover section below.
Please enter a value for Primary Practice State
Please enter a value for Practice Type
Please enter a value for Primary Specialties
Please refer to our Risk Category Guide
Please enter a value for Gross Annual Billings
Gross Annual Billings are the total billings generated by you from all areas of your practice for which you require indemnity from us within the financial year whether the funds are retained by you or not, and before any apportionment or deduction of expenses and/or tax. This includes work performed in your name or work for which you are personally liable, including but not limited to Medicare benefits, payments by individuals, payments by the Commonwealth Department of Veteran’s Affairs, workers compensation schemes and third party insurers. It also includes income received from other healthcare services provided by you such as professional fees, writing articles, incentive payments and overseas work for which we have agreed to extend indemnity under the policy. You do not need to include billings or income from healthcare services that you provide in the public system for which you have access to indemnity from the public hospital or your employer.
Please enter a value for Qualifications
Please list your qualifications including your medical degree and any specialist fellowships that you have been awarded
Please enter a value for Date(s) qualifications obtained
Please provide the exact dates that you graduated medical school, and if applicable, the exact dates you were awarded any specialist fellowship qualifications.

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?

Yes
Please select a Date
No
Not sure, please contact me
Please select a value this question

Comments

The space below is provided for you to enter any additional information that will assist us with issuing you with the most accurate quote. In some case we may need to contact you to discuss your indemnity requirements and if this is the case we will do so with the contact details you provide above.




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