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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 $227.98 (includes GST $19.75)

Nuclear Medicine Technologists, Radiographers $252.18 (includes GST $21.75)

Cardiac Technologists $252.18 (includes GST $21.75)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $379.23 (includes GST $32.25)

Registered Nurse DIV 1 (EMPLOYEE) $172.32 (includes GST $15.15)

Enrolled Nurse DIV 2 Medication Certified $158.40 (includes GST $14.00)

Enrolled Nurse DIV 2 Non Medication Certified $150.74 (includes GST $13.35)

Self-Employed Registered Nurse DIV 1 $227.98 (includes GST $19.75)

Personal Care Attendant $150.54 (includes GST $13.35)

Volunteer Registered Nurse $140.25 (includes GST $12.50)

Occupational Therapists $140.25 (includes GST $12.50)

Paramedics $227.98 (includes GST $19.75)

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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