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Megalines Insurance And Risk Advisers

For over 12 years, we have been relentless in building quality and effective Insurance programs for our teeming Clients in various Industries and of every size.

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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
Director’s Name*
Signature*
Date*
DD slash MM slash YYYY
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Address

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

Postal Address

PO BOX 6353
Point Cook VIC 3030

Phone

+61 3 8379 7300

Fax

+61 3 8677 9344

Email

info@megalines.com.au

Mega Lines Pty Ltd | AFSL 495082 | ABN 68 122 341 191 | Megalines Insurance & Risk Advisers is a trading name of Mega Lines Pty Ltd
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