Quote Request Form
 

Quote Request for Professional Indemnity Insurance

Note: If you are a practice manager or owner please download Practice Policy Pricing Indication Request

Personal Details

Title
*
Please enter a value for Title
First Name
*
Please enter a value for First Name
Middle Name
Surname
*
Please enter a value for Surname
Gender
*
Please select a value for Gender
Date of Birth
*
Please select a value for Date of Birth

Please ensure you have provided at least one of the following:

1 - Mobile number 2 - Home Phone number 3 - Practice Phone number 4 - International Phone Number

Australian Mobile Number
*
Please enter either a mobile, home or work phone number
Checking Australian Mobile Number
Invalid Australian Mobile Number.
Australian Home Phone
Invalid Australian Phone number
Australian Practice Phone
Invalid Australian Phone number
International Phone
Invalid International Phone number
Email
*
Invalid Email address
Address
*
Please enter a value for Correspondence Address
Country
Address line 1
*
Please enter a value for Address line 1
Address line 2
Address line 3
Suburb
*
Please enter a value for Suburb
State
*
Please enter a value for State
Postcode
*
Please enter a value for Postcode
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

Practice Details

When would you like your policy to start?
*
Please select a valid Policy Start 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 your policy start date. You are able to include cover for any practice prior to this date by completing the retroactive cover section below.
Primary Practice State
*
Please select a valid Primary Practice State
Primary Specialty
Please refer to our Risk Category Guide
*
Please select a valid Primary Specialty
Practice Type
*
Please select a valid Practice Type
Gross Annual Billings (not your income or salary) for current financial year
*
Please enter a valid Gross Annual Billings

What to include :

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. This is 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 Veterans' Affairs, workers' compensation schemes and third party and/or vehicle insurers
  • 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.

What not to include :

You do not need to include any billings or income from non clinical work or healthcare services that you provide for which you have access to indemnity from a public hospital's indemnity scheme or your employer.

Have you received a fellowship recognised by the Australian Medical Council (AMC) ? *
Please select a value
If yes, please confirm which fellowship
*
Please select a valid Fellowship
Date fellowship received
*
Date fellowship received
Are you currently enrolled in an accredited training program recognised by AMC? *
Please select a valid College Training Program
Which college training program are you or will you be enrolled in?
*
Please select a valid Training Program
Expected date of fellowship
*
Please select a valid Expected Date of Fellowship
AHPRA Registration Number
*
To search for your registration number, please click here
Please enter AHPRA number
Your Previous Practice
To ensure you have ongoing cover for your previous practice, we will provide you with a quote for retroactive cover
When did you or when will you first commence practice in Australia?
*
Please select a date
Has your practice (specialty, type and billings) changed in the last 5 years? *
Please select yes or no
Have you ever been the subject of a claim, investigation, or complaint? *
Please select yes or no
Please provide information about your previous practice using the table below
Policy Period Type Of Practice Primary Speciality Previous Gross Annual Billings
2023/2024 * * *
2022/2023
2021/2022
2020/2021
2019/2020

What to include :

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. This is 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 Veterans' Affairs, workers' compensation schemes and third party and/or vehicle insurers
  • 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.

What not to include :

You do not need to include any billings or income from non clinical work or healthcare services that you provide for which you have access to indemnity from a public hospital's indemnity scheme or your employer.

Qualification Details

Country of initial medical degree
*
Required
Medical School/University
*
Required
Initial Qualification awarded (example: MBBS or MD)
*
Required
Year Awarded
*
Required

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 cases 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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