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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 $306.32 (includes GST $25.73)

Nuclear Medicine Technologists, Radiographers $353.51 (includes GST $39.63)

Cardiac Technologists $353.51 (includes GST $29.63)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $544.09 (includes GST $45.41)

Registered Nurse DIV 1 (EMPLOYEE) $233.73 (includes GST $19.73)

Enrolled Nurse DIV 2 Medication Certified $212.85 (includes GST $18.00)

Enrolled Nurse DIV 2 Non Medication Certified $201.05 (includes GST $17.03)

Self-Employed Registered Nurse DIV 1 $306.32 (includes GST $25.73)

Personal Care Attendant $201.05 (includes GST $17.03)

Volunteer Registered Nurse $185.63 (includes GST $15.75)

Occupational Therapists $185.63 (includes GST $15.75)

Paramedics $306.32 (includes GST $25.73)

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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