Doctors Professional Liability Insurance Proposal Form

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Doctors Professional Liability Insurance Proposal Form Powered By Docstoc

The Purpose of this Proposal Form is to set out all relevant information for your adviser to submit on your behalf to the insurer(s).
Under the Insurance Contracts Act 1984, you are under a duty to make full disclosure in this Proposal Form as follows:

Your Duty of Disclosure
Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contract Act 1984 to
disclose to the insurer every matter that you know or could reasonably be expected to know, is relevant to the insurer’s decision
whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer
before you renew, extend, vary or reinstate a contract of general insurance.

Your duty however does not require disclosure of matters –

        that diminish the risk to be undertaken by the insurer;
        that is of common knowledge;
        that your insurer knows, or in the ordinary course of their business, ought to know;
        as to which compliance with your duty is waived by the insurer.

If you fail to comply with your duty of disclosure the insurer may be entitled to reduce its liability under the contract in respect of a
claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the opportunity of voiding the contract
from its beginning. There are other matters of which you should be aware in relation to the proposed professional indemnity
insurance, as follows:

Claims Made
The proposed Professional Indemnity insurance policy is claims made and notified insurance i.e. it only covers claims made against
you and notified to the insurers during the period of insurance. However, provided that you give the insurers notice of any
circumstances that may give rise to a claim against you immediately you become aware of these facts and during the period of
insurance, then this insurance will respond notwithstanding that no claim has actually been made against you during the period of

Retroactive Liability
There is provision in the proposed Professional Indemnity, Directors & Officers Liability, Fidelity and Employment Practices Insurance
Policies for the operation of a retroactive date. Claims which subsequently arise from circumstances which occurred prior to the
retroactive date are excluded.

Liability Assumed Under Agreement
The proposed Professional Indemnity, Directors & Officers Liability, Fidelity and Employment Practices Insurance policy excluded
liability arising out of any obligation assumed by way of warranty, guarantee or indemnity to the extent that such liability exceeds the
liability which would have been incurred in the absence of such obligation.

Utmost Good Faith
A contract of insurance is based on the utmost good faith requiring the insurers and the insured to act towards each other with utmost
good faith in respect of any matter arising in relation to the insurance.

We are committed to protecting your privacy. To provide you with our services, which include negotiation and acquisition of insurance,
we need to obtain certain information from you and pass it on to the third parties who are necessary to assist us in providing these
services to you. These include insurers, accountants, lawyers and other advisers. We use the information you provide to advise about
and assist with your insurance needs. We do not trade, rent or sell your information.

For further information about our Privacy Policy, ask for a copy or visit our website -
                                                   Age Care Services – Professional Indemnity & Liability Insurance Proposal Form
All questions in this proposal form must be answered
Period of insurance:             From                                            To                                            At 4pm

Name of organisation (Insured Entity)
Service name (Trading Name)
Postal address
                                                                                              State                Postcode
Phone Number                                                                           Fax Number
Website Address                                                                       Email Address
All business addresses to be covered
                                                                                               State               Postcode
                                                                                               State               Postcode
                                                                                               State               Postcode
Please provide detailed business description, including all activities and services provided

Details of any anticipated changes to the insured's occupation and/or activities for the ensuing 12 months?

Activity                           Bed/Places                                    Activity                                       Number
Nursing Home - High care                                                         CACP Programmes
Hostel - Low care                                                                HACC Programmes
Self Care / Retirement / ILU                                                     EACH Programmes
                                                                                 Respite Care Programmes
                                                                                 Other care activities - Attach full details
Are you duly Licenced/Accredited in accordance with the law?                                                              Yes or No
When does your current Licence/Accreditation expire?
Have you been advised or is there any reason to suspect that accreditation will not be granted in the future?
                                                                                                                          Yes or No
If 'Yes', please provide details

Date founded                                                        Years operated by present owners

Has the business ever traded under a different name? If 'Yes', please provide details                                     Yes or No

Are you a registered Not-For-Profit (Charitable) organisation? Which Professional Associations are you a
                                                                                                                          Yes or No
member of? -Include membership number

Are your insurances subject to stamp duty exemption?                                                                      Yes or No
If 'Yes', what is the exemption certificate date and number?

Please attach a copy (NB should the name of the Insured Entity differ from the name on the stamp duty exemption certificate, you
may not be able to obtain exemption)
Please state your Gross Operational Income (including resident fees and Government subsidies) over the past 3 years
Year20         $                                 Year20         $                            Year20         $
Please indicate the approximate percentage of fees/turnover derived in each state or overseas and the number of staff in each state or

                       NSW         VIC          QLD            SA           WA           TAS           NT           ACT          O/SEAS

                                                     Age Care Services – Professional Indemnity & Liability Insurance Proposal Form

1. Limit of Indemnity required              $
2. Please state number of employees engaged in the following classifications
Registered Nurses                      Maintenance                                     CACP Staff
Enrolled Nurses                        Kitchen/Catering/Laundry                        HACC Staff
Care Service Workers                   Hairdressers                                    VHC (Veterans Home Care)
Clerical/Admin/Managers                Podiatrist                                      EACH (Extended Aged Care at Home)
Nurse Unit Manager                     Divisional Therapist                            Physiotherapist
3.    Are any of the employees noted above engaged in more than one classification?
                                                                                                                            Yes or No
      Eg. staff involved in CACP/HACC programmes. If 'Yes', please provide details.

4.    Will you ensure to the best of your ability that:
      (i) All medical practitioners who provide any services are at all times insured against professional liability
                                                                                                                            Yes or No
           through the MD.U. or similar?
      (ii) All statutory obligations, by-laws and regulations imposed by any Public Authority for the safety of
                                                                                                                            Yes or No
           persons or property are complied with?
      (iii) All nursing staff who provide any services are registered and fully qualified and that this information is
                                                                                                                            Yes or No
            recorded? If 'No', to any of the above, please provide details

5. Do you operate any clinics where you employ Doctors/Dentists etc.? If 'Yes', please provide details                      Yes or No

6. (i) How many clients/ patients do you have on your database?
     (ii) And how many clients do you service per year?
7. In relation to the permanent staff (including directors, excluding admin) What is the total number of clients serviced
   for years.
8. Similarly with your casual staff how many clients do they service?
9.. Is it the same clients they service weekly/ fortnightly or different clients each visit?
10. Are there any expected changes to the above over the next 12 months?
     If yes, please provide details

11.In relation to 'Respite - for carers', please provide details of the type of service offered:

12.Do you provide the following services and if so, please provide the number of patients per annum:
     SERVICE                                                                                                 PATIENTS PER ANNUM
Wound management
Asthma & diabetes care
Medication supervision
Continence management
Pain management
Palliative Care
Health assessment
Meals preparation

                                                          Age Care Services – Professional Indemnity & Liability Insurance Proposal Form

  Meals delivery


 1. Limit of Indemnity required             $

 2. Total employee numbers
 3. Please state your annual payroll (including earnings of principals, directors, partners) over the last 3 years
    Year20         $                             Year20        $                                    Year20         $
 4. (i) Do you engage or intend to engage the services of contractors and/or sub-contractors?                                Yes or No
    (ii) If 'Yes', do you strictly maintain a program to ensure control over contractors and/or sub-contractors? If 'Yes',
                                                                                                                             Yes or No
         please provide details

 5. Please provide details of work performed and wages/fees paid to your contractors and/or sub-contractors? (Labour only)

 6. In terms of your contractual arrangement, do you insist being named either as a Principal or as a Joint Insured
    under Workers Compensation (where applicable) and Liability policies issued to your contractors and/or sub-              Yes or No

 7. Do you hire or intend to hire from other company's additional labour not forming part of your permanent staff?
                                                                                                                             Yes or No
    If 'Yes', provide details of work performed by this component of your labour force

 8. Provide numbers of hired labour

 9. Wages paid                                        $
10. In terms of your contractual arrangement for labour hire and contractors what are the details in regard to work safety, supervision
    and Workers Compensation issued?

11. Please provide details of any proposed fund raising activities? (eg fete, street stalls etc)

12. Please provide details if you hire-out any of your facilities? (eg halls, offices, pools etc)

                                                      Age Care Services – Professional Indemnity & Liability Insurance Proposal Form


1. Previous Claims/Loss History
   Has there been or is there now pending against the Insured Entity, any Insured Person, Director or Officer of the
   Insured Entity or any Subsidiary Companies or against any outside director for any claim in respect to
   Professional Indemnity, or Combined General Liability during the last ten years or has there been any acts of
   dishonesty?                                                                                                              Yes or No

Date of        Date of             Amount         Amount          Amount            Class of claims and details including nature of the
incident       claim               claimed        paid            outstanding       allegations and details of the claimant

                                   $              $               $

                                   $              $               $

                                   $              $               $

2. Has there been any claims circumstances or losses which may lead to a claim being lodged against the Insured
   Entity and/or Insured Persons or losses suffered by the Insured Entity which were not covered by insurance as no         Yes or No
   policy was in force at the time? If 'Yes', please provide details

3. After investigation, is any of the Insured Persons, Directors, Officers or Employees aware of any facts, incidents,
                                                                                                                            Yes or No
   acts, events or Circumstances/complaints involving the molestation of any resident/patient?

4. After investigation, is any of the Insured Persons, Directors, Officers or Employees aware of any facts, incidents,
   acts, events or circumstances/complaints which might give rise to a claim being made against them, the Insured           Yes or No
   Entity or any of their Subsidiary Companies for any of the risks now proposed?

Date            Details including nature of the allegations and details of the claimant

5. Details of previous insurance held

Class of Insurance                      Insurer                           Expiry date     Limit of liability          Excess

Professional Indemnity                                                                    $

Combined General Liability                                                                $

6. Has an application for Professional Indemnity or Combined General made by you or your predecessors in business ever:
   (i) been declined?                                                                                          Yes or No
   (ii) been cancelled?                                                                                        Yes or No
  (iii) had special terms imposed?                                                                                       Yes or No
If 'Yes', please provide details

                                                   Age Care Services – Professional Indemnity & Liability Insurance Proposal Form


I/we declare that the statements and particulars in this proposal are true and that I/we have not mis-stated or suppressed any material

I/we agree that this proposal form with any other information supplied on behalf of the business shall form the basis on any Contract
of Insurance effected thereon. I/we undertake to inform the Insurer of any material alteration to these facts whether occurring before
or after completion of the Contract of Insurance.

We acknowledge receipt of the Important Notices which were attached to this Proposal and that we have read and understood the
contents of that Notice. We further acknowledge that all/part of this proposal may not have been completed in our own hand and that
we have carefully read this proposal and confirm that all the answers given are true and correct and should be taken as having been
completed by ourselves.

Signatures of Managing Director/President and one other executive officer.

Signature:                                       Position:                                        Date:


Description: Doctors Professional Liability Insurance Proposal Form document sample