Alternative/Complementary Medicines and Therapies Insurance Proposal Form
OAMPS INSURANCE BROKERS LTD
ABN 34 005 543 920 AFSL 238312 Ref: 0245-30JAN09

To apply for Practitioner Insurance with our Brokers OAMPS, please fill in the following Proposal Form and click Submit.

Note: Once your online application has been submitted via the online form below, this is act as a cover note for insurance cover, however we will confirm the premium and period of insurance once we have reviewed your application.

If you have any questions on how to fill in this form call OAMPS:
Free Call: 1800 222 012 or Free Fax: 1800 000 472
or email: naturaltherapists@oamps.com.au

* Required

Period of Insurance

The initial policy period will run to the common due date (which is the 31st December), thereafter it will be renewed annually. If you require cover from a specific date please advise:
Date from:

To:

Name of Professional Body *

IICT Membership Number *

Level of Membership *
Full
Associate
Affiliate

Your Details

Title
DR MISS MR MRS MS

First Name *

Last Name *

Trading/Business Name (if applicable)

ABN

Postal Address

Street/PO Box # *

Suburb/City *

Post code *

Country *
Australia
New Zealand

Your Contact Details

Home Tel *

Fax

Email Address *

Work Tel

Website

Mobile

Modality(s) Practiced

Modality(s) Practiced – Accredited/Recognised by the IICT (If practicing a beauty modality please advise % of your working time. Please specify the types of treatments offered, ie: waxing, eyelash tinting, facials, manicures etc.) *

Attach scans of qualification document(s) (up to five scans, 10Mb total limit)

Modality(s) Practiced – Not Accredited/Recognised by the IICT (if applicable)

Attach scans of qualification document(s) (up to five scans, 10Mb total limit)

Claim Questions

After full enquiry, are you aware of any: a) claim having been made against you or any of your business partners? *
Yes
No

b) circumstances which could give rise to a claim against you in the future? *
Yes
No

Have you ever made a claim for property loss or damage in respect of which cover is being sought? *
Yes
No

Have you ever had any insurance declined, cancelled, renewal refused, special conditions imposed special excess imposed or a claim rejected? *
Yes
No

Have you been declared bankrupt or put into receivership of voluntary liquidation? *
Yes
No

Have you been charged or convicted of any criminal offence? *
Yes
No

If you have answered yes to any of the above questions please provide details.

Please indicate the Limits you require

For indicative pricing please click here. Public Liability *
$10 million
$20 million

Professional Indemnity and Products Liability *
$1 million
$2 million
$5 million
$10 million

Do You Employ Other Practitioners?
(A maximum of four practitioners, including the insured, can be covered by this policy)

Name of Practitioner #1

Modality(s) practised by Employee #1

Name of Accrediting Professional Body/Association of Employee #1

Name of Employee #2

Modality(s) practised by Employee #2

Name of Accrediting Professional Body/Association of Employee #2

Name of Employee #3

Modality(s) practised by Employee #3

Name of Accrediting Professional Body/Association of Employee #3

Optional Extentions

Do You Teach Students to Become Professional Practitioners? *
Yes
No

If yes, please indicate the % of your working week spent teaching
0% - 10% of working time
11% - 30% of working time
31% - 50% of working time

Do you require the Legal Expenses Extension for an Additional Premium of $40 plus government charges?
Yes
No
Do you require cover for General Property for an additional premium of $25 per $1,000 of sum insured ?
Yes
No

If Yes, please provide details of the items to be covered and their respective value/s in the box below.

Do you require this policy to be extended for Retrospective Liability for an Additional premium of $25 plus government charges? (This is only payable in your first year of cover)
Yes
No

If Yes, please indicate the date which you would like retrospective liability cover activated on your policy.

Are you qualified to sell/dispense/provide/produce all the products which you provide ? *
Yes
No

If No, please list any products that you are not qualified to sell/ dispense/ provide/ produce.

What is the estimated annual turnover from products you sell, dispense or produce? *

Are you selling/exporting product to the USA/Canada, even if via the internet? (your policy will not cover you for bodily injury or property damage occurring in the United States of America, Canada or their dominions or protectorates) *
Yes
No

Declaration
1) I have made all necessary enquiries into the accuracy of the responses given in this Proposal.
2) The statements and particulars given in this Proposal are true and complete, and that no material facts have been omitted, misstated or suppressed.
3) Should any of the information given by me alter between the date of this Proposal and the inception date of any Insurance Policy, I will give immediate notice thereof to Insurer(s) via OAMPS, and I agree that Insurer(s) may alter or withdraw the terms that they have offered.
4) I agree that if there are any changes during the Policy Period to the declared Business Activities I will promptly notify Insurer(s) via OAMPS.
5) I have read and understood the Important Notices contained in this Proposal.
6) I agree that this Proposal, together with any additional information contained in an appendix or attachment, will form the basis of the contract of insurance effected by Insurer(s).
7) I agree that submitting this Proposal for the purposes of obtaining a quotation does not bind Insurer(s) to complete an Insurance Policy.
8) I will provide Insurer(s) with notice via OAMPS as soon as practicable of any fact or circumstance that might give rise to a Claim, and furnish all relevant documentation to Insurer(s) in the investigation or defence of any Claim.
9) Insurer(s) are hereby authorised to make any investigation and inquiry in connection with this Proposal that they deem necessary.

Click in box to affirm Declaration above *

DUTY OF DISCLOSURE
Before entering into a contract of general insurance, you have a duty, under the Insurance Contracts Act 1984 (Cth), to disclose to the Insurer every matter that you know or could reasonably be expected to know, that is relevant to the Insurer’s decision about insuring you and if so, on what terms.

Your duty does not require disclosures of matters-
− That diminish the risk;
− That are of common knowledge;
− That the Insurer knows, or in the ordinary course of its business as an insurer, ought to know;
− As to which compliance with your duty of disclosure is waived by the Insurer.

You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance.

NON-DISCLOSURE
If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce its liability under the policy in respect of a claim or may cancel the policy. If your no-disclosure is fraudulent the Insurer may avoid the policy from its inception. This is why it is vital that enquiry must be made of all relevant principals, directors, employees, contractors, and subsidiaries before this Proposal is signed by or on behalf of the prospective Insured.

UTMOST GOOD FAITH
Every insurance contract is subject to the doctrine of utmost good faith, which requires that parties to the contract should act toward each other with the utmost food faith. Failure to do so on your part may prejudice any claim of the continuation of cover provided to the insurer.

CHANGE OF RISK OR CIRCUMSTANCE
It is vital that you advise us of any departure from your “normal” form of business (i.e. the business details that have been advised to your Insurer). For example, any change to business activities, ownership, acquisitions, changes in location, or new overseas activities.

SUBROGATION
You may prejudice your rights with regard to a claims if, without prior agreement from the Insurer, you make an agreement with a third party that will prevent the Insurer from recovering the loss from that party of another party.

UNDER INSURANCE
Your property is insured for reinstatement and replacement costs and as such the insured amounts should represent the full replacement value at new costs. If this is not done any claim you make for these costs may not be paid in full.

I have read and understood the DUTY OF DISCLOSURE Notice.
(click in box to affirm) *

Enter Word Verification in box below *
(re-type the letters in the black box, in the white box below)

Note: Once you click 'Submit' your cover note will be in effect and OAMPS will send through confirmation of the cover provided and send an account for the amount payable based on your submission requirements.