RIB - Homeopathy Insurance Information Request

Homeopath Insurance Information Request Form
Broker Email Address - a copy of the form will be sent to this address
example@example.com
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: 0000000000.
Insured Details
Insured Name - Business Name or First/Last Name
Business Type
Website
Policy Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date Business Established

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Modalities Performed
List Other Modalities
Are you qualified to carry out the modalities practiced?
What Professional Indemnity Limit do you require?
What Public / Products Liability Limit do you require?
Estimated income, next twelve months, derived from the selected modalities
$
Estimated wages paid to self, next twelve months
$
Are you intending on employing any staff, other than yourself?
Are you intending on employing any contractors?
What State/Territory do you practice in?
Claims History
Have any claims or complaints ever been made against you?
Are you aware of any circumstances which may result in a claim against you?
Has any insurer ever declined, cancelled or imposed special conditions in relation to any insurance?
Are you currently engaged in (or about to enter into) civil proceedings of either a professional or personal nature?
Have you ever been subject to disciplinary proceedings for professional misconduct by a professional associations or any statutory registration board or been called upon to respond to a complaint?
If yes, please provide full details of claim
Should be Empty:

Homeopath Insurance Information Request Form

Insured Details

Claims History