Self Employed Carer Insurance

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State Postcode Country

Employees (Business owner included)*

Estimated Annual Revenue*

Inception Date

Expiry Date

Your Professional Idemnity Cover

What level of Professional Idemnity Cover do you required?

What level of Public Liability cover do you require?

As at today's date does the insured have Professional Indemnity Insurance currently in force that has been paid for?

Yes
No

As at today's date does the insured have Professional Indemnity Insurance currently in force that has been paid for?

Yes
No

Revenue by activity split

Please specify your revenue by business activity.

Personal Carer (excluding nurses)

Total sum must be 100%
Total: 100%

Do you perform any medical treatments or procedures that are required to be undertaken by a qualified medical practitioner?

Yes
No

Are you appropriately qualified and/or have you completed the appropriate training to perform this activity?

Yes
No

In the last 10 years, have any claims for a breath of professional duty been made against the Business, its predecessors In business or it's current or former partners/principals/directors or employees?

Yes
No

After enquiry, are you aware of any circumstances which may result In a claim 0 against the business or any of its Partners. Principals. Directors or employees?

Yes
No

In the last 10 years. has your business or you or any partner or director.

Yes
No

Had any business insurance/liability claims?
Had any Insurance declined or cancelled?
Suffered any loss or damage which would have been covered by the proposed Insurance policy?
Been convicted of any criminal offence?
Been liable for any civil offence or pecuniary penalties?
Been declared bankrupt or involved In a business which became insolvent?

Signature

This electronic signature will be treated the same as if signed personally.*

This is signature..

Name

Carer Insurance

Carer Insurance

Your Professional Idemnity Cover

Revenue by activity split

Signature

Insurance Quote

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