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Your Name Mr Mrs Ms Miss *

Email Address *

Home Phone

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Your Address *

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Postcode *

State *

Date of Birth *

AHPRA Registration No *

Qualifications *

Employer *

Nurse Practitioners & Students $464.53 (includes GST $39.30)

Nuclear Medicine Technologists, Radiographers $529.87 (includes GST $44.70)

Cardiac Technologists $529.87 (includes GST $44.70)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $874.72 (includes GST $73.20)

Registered Nurse DIV 1 (EMPLOYEE) $341.11 (includes GST $29.10)

Enrolled Nurse DIV 2 Medication Certified $310.86 (includes GST $26.60)

Enrolled Nurse DIV 2 Non Medication Certified $292.71 (includes GST $25.10)

Self-Employed Registered Nurse DIV 1 $464.53 (includes GST $39.30)

Personal Care Attendant $292.71 (includes GST $25.10)

Volunteer Registered Nurse $269.72 (includes GST $23.20)

Occupational Therapists $269.72 (includes GST $23.20)

Paramedics $464.53 (includes GST $39.30)

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%)