Test Renewal Form THIS IS ONLY A TEST FORM, PLEASE DO NOT COMPLETE. "*" indicates required fields Contact InformationName* Prefix Mr.Mrs.MissMs. First Last Email Address* Home PhoneBusiness PhoneMobile Phone*Your AddressAddress* Street Address Address Line 2 City State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your DetailsDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Nursewise Member Number* AHPRA Registration Number* Qualifications*Employer* Choose Your CoverageChoose Your Coverage* Div 1 Registered Nurses – $384.12 (includes GST $32.20) Enrolled Nurses Medicine Certified – $351.45 (includes GST $29.50) Enrolled Nurses Non Med Cert – $330.88 (includes GST $27.80) Personal Care Attendants – $330.88 (includes GST $27.80) Nurse Practitioners/ or Students – $520.85 (includes GST $43.50) Self Employed Registered Nurse Div 1 / Perioperative Nurse Surgical Assistants – $520.85 (includes GST $43.50) Qualified Phlebotomists – $351.45 (includes GST $29.50) Reconstructive Cosmetic Nurses – $581.35 (includes GST $48.50) Paramedic – $535.37 (includes GST $44.70) Employed Midwives (including Prenatal and Birthing Suite, employed in Public or Private Hospitals only) – $980.65 (includes GST $81.50) Nuclear Med Technicians – $595.87 (includes GST $49.70) Radiographers – $581.35 (includes GST $48.50) Volunteer Registered Nurse – $305.47 (includes GST $25.70) Occupational Therapists – $305.47 (includes GST $25.70) Cardiac Technician – $595.87 (includes GST $49.70) Enrolled Nurse Medication Certified Self-Employed – $ 520.85 (includes GST $43.50) Coverage Cost $ 0.00 Includes GSTClick here to see our rates table, with breakdown of fees and taxesHistoryAre 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?* Yes No History DetailsPlease provide details*Please tell us why you said YES to any of the history questions. We will contact you for more information if required.Payment InformationPayment Method Credit Card (bank credit card charge to apply 0.87%) Direct Deposit Account Name GAMMAN INSURANCE BROKERS BSB 083004 Account no. 901683638 Credit Card Surcharge Price: $ 0.00 Total Credit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.