Healthcare Professionals Form

If Yes, please provide details:

Please provide details of your revenue and assets:

Do you perform work outside of Australia, or work for clients located overseas? If so, please state the amount of turnover below in AUD:

For the last financial year, please provide a percentage breakdown of gross revenue by state:

For the upcoming period of insurance please provide a percentage breakdown of business activities that you wish to have covered?

I/we acknowledge that:

1. I/we have read and understood the important information provided on the last page of this document in the important information section.

2. I/we are authorised by all those seeking insurance to make this proposal, and declare all information on this proposal and any attachment is true and correct.

3. I/we authorise the underwriter to give to, or obtain from, other insurers or any credit reference service, any information relating to insurance held by me/us or any claim in relation thereto.

4. I/we acknowledge that, where answers are provided in the proposal are not entered by me directly, I/we have checked and certify that the answers are true and correct.