Carollo Horton Professional Indemnity

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

SuburbState

Post Code

Do you provide any professional services other than (a) dispensing of medical products prescribed by a medical practitioner, or (b) treatment advice provided by a registered pharmacist where such advice would normally only be provided by virtue of the qualifications of a registered pharmacist?*

YesNo

Details of other professional services provided

Are you an employee of any of the following (check those that apply):

Registered Pharmacist in Community PharmacyDrug Information Centre, Hospital Dispensary or similarFriendly Society Dispensary

Are you available to fulfil the duties of relieving manager and/or relieving Pharmacist?*

YesNo

Please list which state you work in. If more than one, please estimate the percentage per state (eg: Victoria 50%, NSW 50% or Queensland 100%).*

From what date do you want the policy to start?*

Date

Have you ever been subject to disciplinary proceedings for professional misconduct?*

YesNo

Please provide details

Have any claims for negligence or breach of professional duty been made against you, or have circumstances been notified to insurers that might give rise to a claim?*

YesNo

Please provide details

Declaration:

I declare as follows: (1) I am authorised by each of the other Applicants to make this Proposal. (2) I have read and understood the Notice to the Proposed Insured on the front of this Proposal. (3) I have read this Proposal and the accompanying documents and acknowledge the contents of same to be true and complete. (4) I understand that, up until a contract of insurance is entered into, I am under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Proposal or in the accompanying documents. Although the signing of this Proposal does not bind the Applicants to effect insurance, the Applicants acknowledge that the particulars and statements contained in this Proposal and in the accompanying documents shall be the basis of the contract should a Policy be issued, and further, the Applicants acknowledge that the Proposal and the accompanying documents will be incorporated in the Policy.

Signature*

Professional Indemnity Insurance Application