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Your Name Mr Mrs Ms Miss *

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Your Address *

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Postcode *

State *

Date of Birth *

AHPRA Registration No *

Qualifications *

Employer *

Nurse Practitioners & Students $333.38 (includes GST $30.76)

Nuclear Medicine Technologists, Radiographers $370.88 (includes GST $33.72)

Cardiac Technologists $370.88 (includes GST $33.72)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $571.13 (includes GST $51.92)

Registered Nurse DIV 1 (EMPLOYEE) $244.88 (includes GST $22.26)

Enrolled Nurse DIV 2 Medication Certified $223.13 (includes GST $20.28)

Enrolled Nurse DIV 2 Non Medication Certified $210.38 (includes GST $19.12)

Self-Employed Registered Nurse DIV 1 $333.38 (includes GST $30.76)

Personal Care Attendant $210.38 (includes GST $19.12)

Volunteer Registered Nurse $193.88 (includes GST $17.63)

Occupational Therapists $193.88 (includes GST $17.63)

Paramedics $333.38 (includes GST $30.76)

Yes No Are there any claims alleging a negligent act, error or mission or malpractice currently lodged against you?

Yes No Are you aware of any circumstance which has already occurred which may give rise to a negligent act, error or omission or a malpractice claim being lodged against you?

Yes No Have you been involved in any action which could have or did give rise to a legal dispute arising out of your employment?

Yes No Have you ever been involved in professional discipline procedures?

Yes No Have you ever been refused any insurance, or had a requirement for hasher terms and conditions imposed upon your application for insurance?

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Credit Card (Bank credit card charge to apply .87%)