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NDIS Application Form

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Full Legal Entity Name*
Business address*
Street Address
Contact address (if different from above)
Street Address
Email*
Mobile Number*
Date of Birth*
DD slash MM slash YYYY
Estimated Number of Employees*
Estimated Turnover*
Business Duration
Specific business activity*
- Aged and/or Disability Care Worker
- Support Co-Ordinator for Disability and Aged Care Services
- Other
Please specify*
If more than 1 activity, please specify the percentage split
Limit Required
Professional Indemnity*
- $1M
- $2M
- $5M
- $10M
Public Liability*
- $10M
- $20M
Business Activity
The provision of disabled or aged care services*
- Yes
- No
As at today's date does the insured have Professional Indemnity Insurance currently in force that has been paid for?*
- Yes
- No
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 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?*
- Yes
- No
After 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?*
- Yes
- No
In 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?
- Yes
- No
Who are your NDIS Provider Registration Consultants?*
Please list*
Director’s Name*
Signature*
Date*
DD slash MM slash YYYY
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Address

Victoria
Unit 112, Level 1
22-30 Wallace Avenue
Point Cook VIC 3030

Queensland
WOTSO Chermside
Level 2, Westfield Chermside
Chermside QLD 4032

Postal Address

PO BOX 6353
Point Cook VIC 3030

Phone

VIC +61 3 8379 7300

QLD +61 7 3180 2604

Fax

+61 3 8677 9344

Email

info@megalines.com.au

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Address

Postal Address

Phone

Fax

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