Renewals Fill out the form below to renew your indemnity insurance to ensure you’re always covered. Please note: All prices are shown in Australian Dollars. Contact Information Your Name Mr Mrs Ms Miss * Email Address * Home Phone Bus. Phone Mobile * Address Your Address * Suburb * Postcode * State * Your Details NurseWise Member # * AHPRA Registration No * Qualifications * Choose Your Coverage Nurse Practitioners & Students $464.53 (includes GST $39.30) Nuclear Medicine Technologists, Radiographers $529.87 (includes GST $44.70) Cardiac Technologists $529.87 (includes GST $44.70) Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $874.72 (includes GST $73.20) Registered Nurse DIV 1 (EMPLOYEE) $341.11 (includes GST $29.10) Enrolled Nurse DIV 2 Medication Certified $310.86 (includes GST $26.60) Enrolled Nurse DIV 2 Non Medication Certified $292.71 (includes GST $25.10) Self-Employed Registered Nurse DIV 1 $464.53 (includes GST $39.30) Personal Care Attendant $292.71 (includes GST $25.10) Volunteer Registered Nurse $269.72 (includes GST $23.20) Occupational Therapists $269.72 (includes GST $23.20) Paramedics $464.53 (includes GST $39.30) 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 ever been involved in professional discipline procedures? Payment Information 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 Mastercard Visa Card Number Cardholder Name Expiry Date /