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Your Name Mr Mrs Ms Miss *

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Your Address *

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Date of Birth *

AHPRA Registration No *

Qualifications *

Employer *

Nurse Practitioners & Students $406.00 (includes GST $34.00)

Nuclear Medicine Technologists, Radiographers $455.00 (includes GST $38.00)

Cardiac Technologists $455.00 (includes GST $38.00)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $709.00 (includes GST $59.00)

Registered Nurse DIV 1 (EMPLOYEE) $295.00 (includes GST $24.80)

Enrolled Nurse DIV 2 Medication Certified $268.00 (includes GST $22.50)

Enrolled Nurse DIV 2 Non Medication Certified $252.00 (includes GST $21.20)

Self-Employed Registered Nurse DIV 1 $406.00 (includes GST $34.00)

Personal Care Attendant $252.00 (includes GST $21.20)

Volunteer Registered Nurse $231.00 (includes GST $19.50)

Occupational Therapists $231.00 (includes GST $19.50)

Paramedics $406.00 (includes GST $34.00)

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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