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 $428.00 (includes GST $35.70) Nuclear Medicine Technologists, Radiographers $478.00 (includes GST $39.90) Cardiac Technologists $478.00 (includes GST $39.90) Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) $745.00 (includes GST $61.90) Registered Nurse DIV 1 (EMPLOYEE) $310.00 (includes GST $26.00) Enrolled Nurse DIV 2 Medication Certified $281.00 (includes GST $23.60) Enrolled Nurse DIV 2 Non Medication Certified $264.00 (includes GST $22.20) Self-Employed Registered Nurse DIV 1 $428.00 (includes GST $35.70) Personal Care Attendant $264.00 (includes GST $22.20) Volunteer Registered Nurse $242.00 (includes GST $20.40) Occupational Therapists $242.00 (includes GST $20.40) Paramedics $428.00 (includes GST $35.70) 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 /