Quote Request Form
 

Quote Request for Professional Indemnity Insurance

Provided you meet the eligibility criteria we recommend skipping the Quotation process and submitting a formal application if:

  • You are a Medical Student or an Intern, you can take advantage of our complimentary policies.
  • You are Junior Doctor or a Doctor in Training, we offer policies between $50 - $150.
  • You are Employer Indemnified with no private billings and have not received any previous private income from the provision of medical services.

Please click here to submit a formal application to activate your policy.

Alternatively, if you would like to speak to a consultant directly call 1800 011 255.

Note: If you are a practice manager or owner please download the Practice Policy Pricing Indication Request form.

Personal Details

Do you have a previous Member Number?
Title
*
Please enter a value for Title
First Name
*
Please enter a value for First Name
Surname
*
Please enter a value for Surname
Gender
*
Please select a value for Gender
Date of Birth
*
Please select a value for Date of Birth

Please ensure you have provided at least one of the following:

1 - Mobile number 2 - International Phone Number

Australian Mobile Number
*
Please enter a mobile number
Checking Australian Mobile Number
Invalid Australian Mobile Number.
International Phone
Invalid International Phone number
Email
*
Invalid Email address
Address
*
Please enter a value for Correspondence Address
Country
Address line 1
*
Please enter a value for Address line 1
Address line 2
Address line 3
Suburb
*
Please enter a value for Suburb
State
*
Please enter a value for State
Postcode
*
Please enter a value for Postcode
Preferred Contact Method *
Please select a preferred contact

Comments

The space below is provided for you to enter any additional information that will assist us with issuing you with the most accurate quote. In some cases we may need to contact you to discuss your indemnity requirements and if this is the case, we will do so with the contact details you provide above.

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