Gross Income details |
| *Please select which income category represents your income |
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| *Are you qualified to carry out the modality practiced? |
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Limit of Indemnity |
| *Which Malpractice Limit of Indemnity is required? |
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$10,000,000 Public Liability cover is automatically included. |
| *Which state do you practice in? |
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Claims Cliam History
With regards to this form of insurance;
(a) Have any claims or complaints ever been made against you?
(b) Are you aware of any circumstances which may result in a claim against you?
(c) Has any insurer ever declined, cancelled or imposed special conditions in relation to any insurance?
(d) Are you currently engaged in (or about to enter into) civil proceedings of either a professional or personal nature?
(e) Have you ever been subject to disciplinary proceedings for professional misconduct by a professional association
or any statutory registration board or been called upon to respond to a complaint? |
| *Answer to Claims/Circumstances ----------------------> |
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