Enquiry Form

Medical Indemnity Insurance Application Form

We offer medical indemnity insurance for Australian Registered Medical Practitioners. As a broker we have access to Avant, Miga, Berkshire Hathaway (distributed by Tego) and other insurers. We deliver competitive pricing and market leading cover. You will always receive responsive, professional and expert medico-legal advice and claims support so you can continue to focus on providing quality patient care. Please complete the form to request a none binding, obligation free quick quotation estimate
Email *
example@example.com
How did you hear about us
Get a quick price indication

Please provide some brief information below to obtain a pricing indication
Title:
Dr, Professor..
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Gender: *

Male Female Other
Mobile:
Telephone:
Postcode of practice *
State where you practice
Annual estimated private gross billings

Current Insurance Details
Current Insurer
Current Annual Premium
Renewal date

Day Month Year
Date
Renewal Period *

July January Other
Have you had any claims, complaints, inquests or anything that you may consider could lead to a complaint or claim in the future?

0/1000
Is there anything else you would like to tell us, or ask us, please feel free to note this below?

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Days before your insurance renewal

The clock is ticking
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Profcover Pty Ltd trading as Profmed (ABN 90546883226; CAR No: 403877) is a Corporate Authorised Representative for M&R Insurance Brokers Pty Ltd (ABN 13005 433287; AFSL Lic No: 234939
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Medical Indemnity Insurance Application Form