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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 $238.75 (includes GST $21.70)

Nuclear Medicine Technologists, Radiographers $263.75 (includes GST $23.98)

Cardiac Technologists $263.75 (includes GST $23.98)

Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $397.25 (includes GST $36.11)

Registered Nurse DIV 1 (EMPLOYEE) $179.75 (includes GST $16.34)

Enrolled Nurse DIV 2 Medication Certified $162.25 (includes GST $14.75)

Enrolled Nurse DIV 2 Non Medication Certified $156.75 (includes GST $14.25)

Self-Employed Registered Nurse DIV 1 $238.75 (includes GST $21.70)

Personal Care Attendant $156.75 (includes GST $14.25)

Volunteer Registered Nurse $145.75 (includes GST $13.25)

Occupational Therapists $145.75 (includes GST $13.25)

Paramedics $238.75 (includes GST $21.70)

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%)