Full Legal Entity Name*Business address* Street Address Contact address (if different from above) Street Address Email* Mobile Number*Date of Birth* Date Format: DD slash MM slash YYYY Estimated Number of Employees*Estimated Turnover*Business DurationSpecific business activity* Aged and/or Disability Care Worker Support Co-Ordinator for Disability and Aged Care Services OtherPlease specify*If more than 1 activity, please specify the percentage splitLimit RequiredProfessional Indemnity*$1M$2M$5M$10MPublic Liability*$10M$20MBusiness ActivityThe provision of disabled or aged care services*YesNoAs at today's date does the insured have Professional Indemnity Insurance currently in force that has been paid for?*YesNoDo you perform any medical treatments or procedures that are required to be undertaken by a qualified medical practitioner?*YesNoAre you appropriately qualified and/or have you completed the appropriate training to perform this activity?*YesNoIn the last 10 years, have any claims for a breach of professional duty been made against the Business, it's predecessors in business or it's current or former partners/principals/directors or employees?*YesNoAfter enquiry, are you aware of any circumstances which may result in a claim against the business or any of its Partners, Principals, Directors or employees?*YesNoIn the last 10 years, has your business or you or any partner or director:*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?YesNoDirector’s Name*Signature*Date* Date Format: DD slash MM slash YYYY CAPTCHA