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Fill out the form below to apply for the indemnity insurance nurses can afford.

Please note: All prices are shown in Australian Dollars.

INSURED PERIOD for prices below is 10/08/20 to 15/11/20

Contact Information

Your Name *

Email Address *

Home Phone

Bus. Phone

Mobile *

Address

Your Address *

Suburb *

Postcode *

State *

Your Details

Date of Birth *

AHPRA Registration No *

Qualifications *

Employer *

History

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?

Payment Information

Cheque

Internet Transfer/Deposit

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

Cheque or money order is payable to Gamman Insurance Brokers.

Account Name GAMMAN INSURANCE BROKERS
BSB 083004
Account no. 901683638

Card Type

Card Number

Cardholder Name

Expiry Date /