1. Details of Practitioners to be insured (if more than one practitioner please provide details on separate sheet): First Name Last Name Initial First Practitioner Qualifications Years in practice Memberships Postal Address Street Suburb Fax Phone State Postcode email 2. Please state modalities for which you require cover (please refer to our approved modalities list). Click here to save your information. An email with this information will arrive in your inbox for you to print off and sign. A copy of the Proposal Form will also be emailed to our PI specialist, Michelle Govier. Thank you. Health Professionals Proposal Form Combined Professional Indemnity, Public Liability, Goods Sold or Supplied Insurance Package for Health Professionals Incorporated Company/Partnership (if any) owned by you for your practice (do not repeat your name) Accupoint Therapy Accupressure Accupuncture Alexander Technique Allergy Testers Animal Therapy Aromatherapy Astrology Aura-Kinetic Training Auro Soma Ayurveda BioFrequency BioMagnetic Body Harmony Body Talk Systems Bowen Technique Brain Gym Brandon Raynor Breath Work Buteyko Breathing Method Chinese Medicine Chi Nei Tsan Coaching Colour Therapy Colon HydroTherapy Colonic Irrigation Craniosacral therapy Crystal Therapy Cupping Counsellors DanceTherapy Dietitians Dorn Therapy Dry Needling Ear Candling Electro acupuncture Emotional Freedom Techniques Emmett Technique Endermologie Exercise physiology Facial harmony Feldenkrais Flower remedies Feng shui Healing energy Healing touch Hellerwork Herbalists Homeopathy Herbal medicine Horstmann technique Hypnotherapy Indian Head Massage Iridology Iris diagnosis Lactation consultants Life coaching Lymphatic system Magnetic field therapy Massage Massage - Chinese Massage - Connective Tissue Massage - Corporate Massage - Deep Tissue Massage - Mobile Massage - Pregnancy Massage - Remedial Massage - Swedish Massage - Thai Meditation Mora therapy Moxibustion Music therapy Myofascial release therapy Myopractic Myotherapy Natural fertility management Naturopathic medicine Naturopathy Neuro linguistic programming Numerology Nutiritionists Oriental Health Sciences Personal Trainers Phytotherapy Pilates Polarity therapy Pranic healing Professional Counsellors PSH therapy Psychotherapists Q2 therapy Recreation therapy Reflexology Reiki treatment Remedial therapy Rolfing Structural Integration SCENAR Shiatsu Somatic integration therapy Speech therapy Spiritual healing Tai chi Time line therapy Traditional Chinese medicine Transactional analysis Transpersonal & Emotional Release YogaPSH therapy Vocational counselling Trigger point therapy 3. Are the principles and staff qualified to the generally accepted minimum standards for the modalities practised by each? Yes 4. Are you currently insured? Yes If yes, what is the policy expiry date? Who is your insurer? Life and Income Protection Office Insurance Domestic (house/car/boat etc.) 5. Please complete the relevent boxes indicating the number of practitioners in each category and the limit of indemnity required. Note: If there is more than one practitioner, please provide a seperate list of all practitioners' names along with qualifications and memberships. Category of each practitioner (refer to rating guide for premiums) Select PI limit Category 1. Income above $10,000 per annum Category 2. Income below $10,000 per annum Number of Practitioners $500,000 $1,000,000 $2,000,000 $10,000,000 $5,000,000 6. Claims/Circumstances (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 a professional nature? (e) Have you ever been subject to disciplinary proceedings for professional misconduct by a professional association or other authorised body? Yes Yes Yes Yes Yes 9. I have read and agree to the terms and conditions available at: Yes http://www.alliedhealthpi.com.au/the-fine-print 8. Declaration and Agreement: (a) I/We ackowledge that I/We have read the Notices to the proposed Insured included with this form, and I/We understand those notices. I/We acknowledge that if the proposal is accepted, the insurance cover will be subject to the terms and conditions as set out in the policy wording. (b) I/We declare that the information contained in this proposal form is true and correct and that I/We have not suppressed nor misstated any facts. (c) I/We declare that I/We hold relevant qualification in which I/We practice. 7. Eagle Insurance Brokers are full service brokers. Please let us know if we could assist you with any other insurance solutions: No No No No No No No