QBE PRIMARY HEALTH & COMMUNITY CARE …...QBE PRIMARY HEALTH & COMMUNITY CARE ORGANISATIONS...

Insurance Marketing Group of Australia Pty Ltd - MEDIPROTECT 11a 44 Station Road, Yeerongpilly Q 4105

Po Box 6013 Fairfield Q 4103 Ph: 07 3426 0400 - Fax: 07 3426 0444

ABN: 74 088 790 327 - ACN: 088 790327 AFSL: 234421

PROPOSAL FORM

PART A - ASSOCIATION LIABILITY PART B - CLINICAL PROFESSIONAL INDEMNITY

QBE PRIMARY HEALTH & COMMUNITY CARE ORGANISATIONS INSURANCE PROGRAM (PART A)

Underwritten by QBE INSURANCE (AUSTRALIA) LIMITED

82 Pitt Street Sydney, NSW 2000 Ph: (02) 9375 4444 - Fax: (02) 9375 4992

ABN 78 003 191 035

NOTICE TO THE PROPOSED INSURED (Pursuant to the provisions of the Insurance Contracts Act 1984)

IMPORTANT INFROMATION: Please read the following before completing the proposal questions. 1. DISCLOSURE OF RELEVANT FACTS YOUR DUTY OF DISCLOSURE Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter which you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate a contract of insurance. Your duty however does not require disclosure of a matter that diminishes the risk to be undertaken by the insurer that is common knowledge that the insurer knows or, in the ordinary course of business as an insurer, ought to know as to which compliance with your duty is waived by the insurer. NON-DISCLOSURE If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a Claim or may cancel the contract. If your nondisclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. Comment: The requirement of full and frank disclosure of anything which may be material to the risk for which you seek cover (e.g. Claims whether founded or unfounded), or to the magnitude of the risk, is of the utmost importance with this type of insurance. It is better to err on the side of caution by disclosing anything which might conceivably influence the insurer’s consideration of your Proposal. 2. CLAIMS MADE POLICY This Proposal is for a “Claims made and notified” Policy of insurance. This means that the Policy covers you for Claims made against you and notified to the insurer during the Period of Cover. This Policy does not provide cover in relation to: - acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if such a date is specified); - Claims made after the expiry of the Period of Cover even though the event giving rise to the Claim may have occurred during the Period of Cover;

- Claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy; - Claims made, threatened or intimated against you prior to the commencement of the Period of Cover; - facts or circumstances which you first became aware prior to the Period of Cover, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy; - Claims arising out of circumstances noted on the Proposal form for the current Period of Cover or on any previous Proposal form. However, the effect of Section 40(3) of the Insurance Contract Acts 1984 is that where you give notice in writing to the insurer of any facts that might give rise to a Claim against you as soon as reasonably practicable after you become aware of those facts but before the expiry of the Period of Cover, the Policy will, subject to the terms and conditions, cover you notwithstanding that a Claim is only made after the expiry of the Period of Cover. You should familiarise yourself with our standard form of Policy for this type of cover before submitting this Proposal. Please note that you will be covered for a Claim made or notified against you after the expiry of the Period of Cover if you comply with the requirements of the statutory benefit provided by Section 40(3). There is no right to obtain this protection under the terms of the Policy and the effect of the Policy is that you are not covered for Claims made and notified against you after the expiry of the Period of Cover. 3. THE APPLICANTS FOR INSURANCE In this Proposal the Applicants for insurance are: • The Organisation (that being the company or organisation named in this Proposal); • The Insured Person(s) as defined in the Policy wording; and any Outside Entity or Outside Directorship for which cover is sought. Before completing this Proposal, enquiries should be made with each proposed Insured in relation to the questions and declarations to be completed on their behalf.

I/We have read and understood the above Important Information.

Agree

PART A - ASSOCIATION LIABILITY CHECKLIST - PART ABefore returning this proposal please ensure that your have: - Completed all of the questions. - Saved a copy of the form for future reference. When returning PART A of the form you will also need to provide: - Financials for the last two years, and - Most recent copy of your Organisation's Annual Report. If you require assistance with any aspect of this form, or you are not sure of the content of any question please contact us on Free Call: 1800 177 163. We are more than happy to help.

YOUR ORGANISATION'S NOMINATED CONTACT PERSONDue to Privacy Legislation and our Australian Financial Service Licensing (AFSL) obligations, we ask that you nominate ONE contact regarding insurance matters. Please nominate a person of authority, who is authorised by the Organisation to be our point of contact: Note: please provide: name, email, phone number and mobile

DETAILS ABOUT YOUR ORGANISATIONQ1. Name of your Organisation:

Q2. Address of your main location:

Q3. Phone:

Q4. Fax:

Q5. E-mail:

Q6. Web:

Q7. Organisation ABN:

Q8. Please describe the Organisation's professional services and activities:

Q9. Does your Organisation hold any form of Accreditation?

Yes - please answer question 9a No - proceed to Q10

Q9a. Note: If Yes to previous question (Q9.), please supply details below. Example: Type of Accreditation, year gained, re-accreditation due date/year etc.

Q10. Has the Organisation's professional services or activities changed or altered in the past 12 months?

Yes - Please answer Q10a No - proceed to Q11

Q10a. Note: if you have answered Yes to the previous questions (Q10.), please provide detailed information as to how the activities and / or services of the Organisation have changed in the last 12 months?

YOUR ORGANISATION'S INSURANCE REQUIREMENTSNote: Covers that are automatically included in Mediprotect's Primary Health & Community Care Organisations Insurance program are listed below:

- Professional Indemnity - Directors & Officers - Employment Practices (Insured Vs Insured) - Enquiries & Investigations - Fidelity ($750,000 Sub-limit) - Malpractice & Vicarious Liability - Statutory Fines and Penalties

- Unlimited Retrospective Date - Advanced Payment of Defence Costs - Trade Practices & related legislation - Libel & Slander - Breach of Contract - Fraud & Dishonesty - Severability and Non-imputation - Crisis Cover

- Occupational Health - Loss of Documents - GP Training Activities - Committees - Estates & Legal Representatives - Information & Communication Technology ** - Allied Health Practitioner activities

** ICT activities limited to general advice / recommendations on software and/or system configurations, limited data storage for third parties and limited hosting for third parties. Note: if your activities fall outside this scope you may require a separate ICT liability policy. Please contact Mediprotect on 1800 177 163 to establish if this is the case.

Q11. Please select the Limit of Indemnity your Organisation requires to meet contractual funding requirements?

Renew existing Limit of Indemnity

$10 Million Limit of Indemnity with $20 Million in the Aggregate

$20 Million Limit of Indemnity with $40 Million in the Aggregate

OPTIONAL COVERS AVAILABLE: Please indicate Yes or No - if you require cover for any of the following activities?

Q12. Medical/General Practice or After Hours Clinic

Yes - please complete Part BNo - Proceed to Q13

Q12. Refers to your organisation providing clinical medical services in a separate/additional general practice/GP clinic setting or an "After Hours" clinic. If you select this cover you should also complete PART B of the application.

Q13. Outside Directorship - Blanket Cover

Yes - proceed to Q13

No - proceed to Q13

Q13. You should only select this cover if your Organisation has a board member on another board purely for the purpose of representing your organisation. If you select Yes to this optional cover we will contact you for further information.

Q14. Outside Directorship - Run-off Cover


No - proceed to Q15

Q14. This cover is only required if your organisation has previously had Outside Directorship cover AND has recently ceased this activity. If you select Yes this optional cover we will contact you for further information.

Q15. Trusteeship Cover


No - proceed to Q16

Q15. You should only select this cover if your organisation is performing trustee activities. e.g.: trusteeship of a staff superannuation fund. If you select Yes to this optional cover we will contact you for further information.

Q16. Trusteeship Run-off Cover


No - proceed to Q17

Q16. This cover is only required if you have previously had Trusteeship cover AND you have recently ceased this activity. If you indicate Yes to this optional cover, we will contact you.

YOUR ORGANISATION'S STAFF & CONTRACTORSMEDICAL PRACTITIONERS

Q17. Do you pay Medical Practitioners to carry out medical procedures or provide medical advice direct to patients? Note: "pay" refers to any employment or contract arrangements

Yes - Please answer Q17a No - proceed to Q18

Q17a. If you have answered Yes to the previous question (Q17) please advise:

The FTE estimate of these medical practitioners combined? Note: FTE means Full Time Equivalent. e.g. 1 FTE = 38.5 hours/week and 0.5 FTE = 19 hours/week etc

ALLIED HEALTH PROFESSIONALS

Note: the below list of activities / services are covered automatically:

- Aboriginal Health Worker - Aboriginal Mental Health Worker - Aboriginal Community Officer & Counselling - Aged Care Nurse - Alcohol & Drug Worker - Asthma Educator - Audiologists - Cardiac Rehabilitation Nurse - Care Coordinator - Case Managers - Chiropodist - Chronic Care Registered Nurse - Clinical Psychologist Clinical Nurse - Clinical Psychologist - Community Care Workers - Community Support Worker - Counsellor - CPR Trainer

- Dementia Adviser - Dermatologist - Diabetes Counsellors - Diabetes Educator - Dietician - Drug and Alcohol Worker - EEG Technician - Endocrinologist - Exercise Psychologist - Family Support Worker - Family Therapist - GP Liaison Officer - Immunization Coordinator - Indigenous Cultural Liaison Officer - Indigenous Primary Health Service Development Program Manager - Indigenous Sexual & Reproductive Health Worker - Lactation Consultant - Life Style Educators

- Mental Health Clinician - Mental Health Practitioner - Mental Health - Shared Care Clinician - Mental Health Social Worker - Narrative Therapist - Neurologist - Nurse - Nutritionist - Occupational Therapist - Outreach Worker - Post Natal Support Worker - Practice Support Officer - Primary Health Care Manager - Psychologist QUM/HMR Facilitator - Rehabilitation Consultants - Social Worker - Speech Pathologist / Therapist - Pharmacist - Physiotherapists - Youth worker

Q18. Does your Organisation employe or contract any Allied Health Practitioners that do not appear on the list above?

Yes - please answer Q18a No - proceed to Q19

Q18a. If you have answered Yes to the above question (Q18.), please provide the following information.

Profession (not included in the list above) FTE Contracted or Employed

Contracted Employed


Contracted Employed


Contracted Employed


Contracted Employed


Contracted Employed

Note: FTE = Full Time Equivalent. e.g.: 1 FTE = 38.5 hours/week and 0.5 FTE = 19 hours/week etc.

Q19. Please estimate the total FTE of all contracted Allied Health professionals providing services for, or to, the Organisation?

Q20. Please estimate the total FTE of all employed Allied Health professionals providing services for, or to, the Organisation?

YOUR ORGANISATION'S CLAIMS HISTORYQ21. Have any claims for negligence, or breach of professional duty, been made against your Organisation, or any proposed Insured Person, or have circumstances been notified to the insurers that might give rise to a Claim?


Q21a. Note: If Yes to previous question (Q21.), please supply details below. Example: brief description of: - allegation / act or error - year or date - whether a claim or notification only - outcome - Insured persons involved

Q22. Has your Organisation or any proposed Insured Person been subject to disciplinary proceeding for professional misconduct?



Q23. Are you, after inquiry, aware of any circumstance that might give rise to a Claim against your Organisation or any proposed Insured Person that is not referred to in the above questions?

Yes - please answer Q23a No - proceed to Declaration


DECLARATION - PART AI / We, the undersigned authorised Insured Persons, after enquiry declare as follows: (a) I am /We are authorised by each of the other Applicants to make this Proposal. (b) I / We have read and understood the Notice to the Proposed Insured on the front of this Proposal. (c) I / We have read this Proposal and the accompanying Documents and acknowledge the contents of same to be true and complete. (d) I/We understand that, up until a contract of insurance is entered into, I am/We are under a continuing obligation to immediately inform QBE - via Mediprotect, of any change in the particulars or statements contained in this Proposal, or in the accompanying Documents. (e) 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. Note: Authorised Person is any of the following who have been authorised to sign on behalf of the Organisation: - Chairman - President - Managing Director - Any member of the Board - CEO - CFO - GM - FARM Committee Members - Contracts Officer - Operations Manager

Signature: Name: Date:


Insurance Marketing Group of Australia Pty Ltd - MEDIPROTECT

11a 44 Station Road, Yeerongpilly Q 4105 Po Box 6013 Fairfield Q 4103 Ph: 07 3426 0400 - Fax: 07 3426 0444 ABN: 74 088 790 327 - ACN: 088 790327 AFSL: 234421


11a 44 Station Road, Yeerongpilly Q 4105 Po Box 6013 Fairfield Q 4103

Ph: 07 3426 0400 - Fax: 07 3426 0444 ABN: 74 088 790 327 - ACN: 088 790327 AFSL: 234421

CLINICAL PROFESSIONAL INDEMNITY PROPOSAL FORM - PART B

IMPORTANT INFORMATION: Please read the following before completing the proposal questions. 1. YOUR DUTY OF DISCLOSURE Before you enter into a contract of insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, is relevant to the insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter: that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows, or, in the ordinary course of its business, ought to know; or as to which compliance with your duty is waived by the insurer. NON DISCLOSURE If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. Comment: The requirement of full & frank disclosure is of the utmost importance with this type of insurance. This is particularly the case in respect of anything which may be relevant to the risk for which you seek cover (e.g. claims, whether founded or unfounded), or to the magnitude of the risk. 2. CLAIMS MADE POLICY Claims Made Policy: This declaration is for a “claims made and notified” policy of insurance. This means that the policy covers you for claims made against you & notified to the insurer during the period of cover. This policy does not provide cover in relation to: - acts, errors or omissions actually or allegedly committed prior to the retroactive date of the policy (if such a date is specified); - claims made after the expiry of the period of cover even though the event giving rise to the claim may have occurred during the period of cover; - claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous policy; - claims made, threatened or intimated against you prior to the commencement of the period of cover; - facts or circumstances of which you first became aware prior to the period of cover, and which you knew or ought reasonably to have known had the potential to give rise to a claim under this policy; - claims arising out of circumstances noted on the proposal form for the current period of cover or on any previous proposal form. Where you give notice in writing to the insurer of any facts that might give rise to a claim against you as soon as reasonably practicable after you become aware of those facts but before the expiry of the period of cover, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to be indemnified in respect of any claim

subsequently made against you arising from those facts notwithstanding that the claim is made after the expiry of the period of cover. Any such rights arise under the legislation only. The terms of the policy & the effect of the policy is that you are not covered for claims made against you after the expiry of the period of cover. 3. AVERAGE PROVISION The policy may provide that if a payment in excess of the limit of indemnity available under the policy has to be made to dispose of a claim, the insurer’s liability for costs & expenses incurred with its consent shall be such proportion thereof as the amount of indemnity available under this policy bears to the amount paid to dispose of the claim.

I/We have read and understood the above Important Information.

Agree

PART B - CLINICAL PROFESSIONAL INDEMNITY Note: you should only complete this part of the proposal if you have answered Yes to PART A - Q12.

CHECKLIST - PART BBefore returning this proposal please ensure that your have: - Completed all of the questions. - Saved a copy of the form for future reference. If you require assistance with any aspect of this form, or you are not sure of the content of any question please contact us on Free Call: 1800 177 163. We are more than happy to help.

DETAILS ABOUT YOUR ORGANISATIONQ1. Full name of Insured:

Q2. Please provide the below details?

Location of Practice (Main)Trading name of Practice (if different to above)

Please choose the option that best describes this Locations activities? (Main Location)

GP Practice (minimally invasive procedures) GP Practice ( invasive procedures) e.g.: Vasectomies

Mental Health Clinic "Super Clinic"

Allied Health Only clinic Other - please describe

Location of Practice (Location 2)

Trading name of Practice (if different to above)

Please choose the option that best describes this Locations activities? (Location 2)










Location of Practice (Location 4)Trading name of Practice (if different to above)











Q3. Has the organisation ever engaged in similar activities under another name?


Q3a. If you have answered Yes to the above question (Q3.), please provide details?

Q4. Is your Practice/s located is a Rural or Urban area? Note: where you have more than one location, please choose your answer based on the majority of locations.

Rural Urban

DETAILS ABOUT INCOME, STAFF & CONTRACTORSQ5. Please provide:

Total Annual estimate of Practice/s Turnover Note: all fee income derived from patients & funding before any expenses are paid.

Annual estimate for number of patient consults Note: all consults, including those from Medical Practitioners & any employed Allied Health Staff.

Number of Receptionists

FTE for Receptionists

Number of Practice Nurses

FTE for Practice Nurses

Number of Admin / Practice / Business Managers

Number of Allied Health Professionals NOT declared under PART A above.

FTE for Allied Health Professionals NOT declared under PART A above.

Note: FTE = Full Time Equivalent. I FTE = 38.5 hours/week and 0.5 FTE = 19 hours/week

Q6. Are your Medical Practitioners:

Contracted Employed

Pay The Practice entity a % of fees for services Other - please describe

Q7. Please provide:

Number of Medical Practitioners FTE of Medical Practitioners

DETAILS ABOUT PRACTICE ACTIVITIESQ8. Does the Practice/s hold any form of Accreditation or in the process of obtaining Accreditation?

Yes - please answer question 8a No - proceed to Q9

Q8a. If you have answered Yes to the above question (Q8.), please provide details?

Q9. Does the Practice Manager hold a Diploma or any formal recognised qualification in Healthcare Practice Management?

Yes No

Q10. Does the Practice/s have any of the following? Note: if you answer Yes to either of the following, we will contact you for further information.

Dispensary

Yes No

Pathology Laboratories

Yes No

PRACTICE INSURANCE REQUIREMENTSQ11. Please choose your required indemnity level?

$5 Million $10 Million $20 Million

Q12. Has the Practice/s had any previous Medical Indemnity or Professional Indemnity Insurance?

Yes - please answer Q12a & Q13 (i), (ii) & (iii) No - proceed to Q14

Q12a. If you have answered Yes to the above questions (Q12.), please provide details? Note: Please provide: - Date policy was first incepted - Name of Insurer - Policy number (if known) - Previous indemnity level

Q13. Has a Medical Defence Insurer / Organisation (MDI/MDO) or other Insurer ever:

(i) refused you, a Medical Practitioner or a practice staff member cover or indemnity in respect to a claim on a policy?

Yes please answer Q13a No - proceed to Q13(ii)

(ii) refused you, a Medical Practitioner or a practice staff member; membership or an insurance policy?

Yes - please answer Q13a No - proceed to Q13(iii)

(iii) applied an additional excess or loading to a medical indemnity or professional indemnity policy held by you, a Medical Practitioner or a practice staff member?


Q13a. If you have answered Yes to the above questions (Q14. (i),(ii) or (iii)), please provide details?

Q14. Do you require Retrospective cover?

Yes No

CLAIMS HISTORY Q15. After enquiry are you aware of any incidents, acts, errors or omissions that may give rise to a claim during the Retrospective period?


Q15a. If you have answered Yes to the above questions (Q15), please provide details? Note: Please provide: year of incident and a brief description of incident

Q17. After enquiry are you aware if you, a Medical Practitioner, Allied Health Practitioner or practice staff member:

(i) had any claims made against you or them in the past 10 years? Note: You do not need to declare- property damage claims, motor vehicle claims or workers compensation claims.

Yes - please answer Q17a No - proceed to Q17 (ii)

(ii) been the subject of a AHPRA or Medicare Australia investigation or coronial inquest or inquiry, in the past 10 years, regardless of the outcome or findings?

Yes - please answer Q17a No - proceed to Q17 (iii)

(iii) ever been found guilty of a criminal offence?

Yes - please answer Q17a No - proceed to Q17 (iv)

(iv) received any verbal threat, that may lead to a claim under this policy?

Yes - please answer Q17a No - proceed to Declaration

Q17a. If you have answered Yes to the above questions (Q17 (i), (ii), (iii) or (iv)), please provide details? Note: Please provide: - year of incident / investigation / offence - brief description of incident / investigation / offence - names of parties involved - outcome details

DECLARATION - PART BI / We, the undersigned authorised Insured Persons, after enquiry declare as follows: (a) I am /We are authorised by each of the other Applicants to make this Proposal. (b) I / We have read and understood the Important Information Notice to the Proposed Insured on the front of this Proposal. (c) I / We have read this Proposal and the accompanying Documents and acknowledge the contents of same to be true and complete. (d) I/We declare that the statements and particulars in this proposal are true and correct and the I / We have not mis-stated or suppressed any material facts. (e) 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. Note: Authorised Person is any of the following who have been authorised to sign on behalf of the Organisation: - Chairman - President - Managing Director - Any member of the Board - CEO - CFO - GM - FARM Committee Members - Contracts Officer - Operations Manager




11a 44 Station Road, Yeerongpilly Q 4105 Po Box 6013 Fairfield Q 4103 Ph: 07 3426 0400 - Fax: 07 3426 0444 ABN: 74 088 790 327 - ACN: 088 790327 AFSL: 234421

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