Important Information

Important Information Important Facts Relating To This Proposal Form – You should read the following advice before proceeding to complete this proposal form.

This insurance is arranged by Insurance Cover Agency Pty Ltd t/as Cosmetic Nurse Insurance Hub ABN 23 141 574 914 AFS 344648. Authorised Representative Number 1284487 an Authorised Representative of PSC Connect Pty Ltd ABN 21 141 574 914 AFS 344648.

Duty of Disclosure

Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk of insurance, and if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance.

Your duty, however, does not require disclosure of any matter

a) that diminishes the risk to be undertaken by the insurer;
b) that is of common knowledge;
c) that your insurer knows or, in the ordinary course of his business, ought to know;
d) as to which compliance with your duty is waived by the insurer.

Non-disclosure

If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim, refuse to pay the claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.

What do you need to tell us?

If at any time throughout your policy period you employee staff, work under an ABN not reflected on your application (if you are currently an employee), add treatments or services not listed on your policy under Business or Healthcare Activities, any changes within your business impacting this policy, any changes in the insured entity/name on your policy, or a complaint, circumstances which may result in a claim or a claim arises.

Claims Made and Notified Basis of Coverage

The Professional Indemnity and Liability Insurance Policy is issued on a ‘Claims Made and Notified’ basis. This means that the Insuring Clause responds to:

a) claims first made against you during the policy period and notified to the insurer during the policy period, provided that you were not aware at any time prior to the policy inception of circumstances which would have put a reasonable person in your position on notice that a claim may be made against him/her; and

b) written notification of facts pursuant to section 40(3) of the Insurance Contracts Act 1984. The facts that you may decide to notify, are those which might give rise to a claim against you.

Such notification must be given as soon as reasonably practicable after you become aware of the facts and prior to the expiry of the policy period. If you give written notification of facts the policy will respond even though a claim arising from those facts is made against you after the policy has expired. For your information, section 40(3) of the Insurance Contracts Act 1984 is set out below:

“S40(3) Where the insured gave notice in writing to the insurer of facts that might give rise to a claim against the insured as soon as was reasonably practicable after the insured became aware of those facts but before the insurance cover provided by the contract expired, the insurer is not relieved of liability under the contract in respect of the claim when made by reason only that it was made after the expiration of the period of the insurance cover provided by the contract.”

When the policy period expires, no new notification of facts can be made on the expired policy even though the event giving rise to the claim against you may have occurred during the policy period. You will not be entitled to indemnity under your new policy in respect of any claim resulting from an act, error or omission occurring or committed by you prior to the retroactive date, where one is specified in the policy terms offered to you. Our policy contains a provision that has the effect of excluding or limiting our liability in respect of a liability incurred solely by reason of the Insured entering into a deed or agreement excluding, limiting or delaying the legal rights of recovery against another.

    section 1
    Details about you and your business
    Your full name:
    Name of person/business to be insured:
    Please note: A trust is not an insurable entity, provide the details of the trustee of the trust and the ACN if a company
    ABN:
    Date of business establishment or commencement of employment:
    How many years have you been providing non-surgical cosmetic procedures:
    Please select if you are a:
    For registered health practitioner applicants, please provide your registration number:
    Principal business address:
    Other addresses:
    Email address:
    Website address:
    Mobile phone:
    section 2
    Treatments and services
    Please select the treatments and/or services you provide:
    Have you discontinued any treatment(s) previously insured under this or another provider’s policy:
    Do you manufacture, alter, repackage (ie white label skin care) or purchase any product directly from oversea any products:
    Please note: Do not tick Yes due to reconstitution of injectables
    Have you directly purchased any device or equipment from outside Australia for use in your clinic:
    Do you and any employees/contractors possess the necessary qualifications...
    Do you obtain medical history or client information in all cases?
    Do you obtain informed consent for all treatments/services provided?
    Do you maintain accurate descriptive records of all treatments/services provided?
    section 3
    Your insurance requirements
    Limits of insurance required:

    Professional Indemnity limit
    Public-product liability limit
    section 4
    People in your practice
    Sole traders
    Do you have any employees/contractors:
    If you answered No, please go to Section 5.
    If you answered Yes, please complete the staff section.
    Employees
    Are you an employee in a clinic not working under your own ABN:
    If you answered No, please go to Section 6.
    Company or Partnership
    Please list details of all directors or partners of the business (including yourself):
    Name
    Qualification
    Date Qualified
    Commencement Date this Practice
    Is any Director or Partner connected or associated...
    Do you have any employees/contractors:
    For businesses with employees and contractors, please complete details of all people engaged to work in the business:
    Qualification
    Number of Employees
    Number of Contractors
    Qualifications
    Registered Nurse
    Nurse Practitioner
    Enrolled Nurse
    Dermal Therapist
    Beauty Therapist
    Administrative
    Other (please specify)
    section 5
    Financial Information
    Please select the turnover category which accurately reflects your business turnover for last financial year and the estimate this financial year:
    Please provide an estimate percentage of your activities (based on income) applicable to each State or Territory – must total 100%:
    NSW
    VIC
    QLD
    SA
    WA
    TAS
    NT
    ACT
    section 6
    Questions about your practice
    Does the insured have procedures in place that comply with all applicable regulations in respect of sterilisation of instruments, and the safe disposal/storage/collection of all waste including sharps, dressings, blood products, hazardous waste:
    Are you aware of, and do you comply with, the current guidelines for Healthcare Practitioners providing non-surgical cosmetic procedures:
    Do you have a complaints procedure in place:
    Is the insured required to be licensed or accredited in order to practice the professional treatments/ services and if Yes, confirmation any license or accreditation is current and in force:
    Do you engage consultants or contractors:
    Do you perform work outside of Australia, or work for clients located overseas?
    section 7
    Insurance and claims history
    During the past 6 years has the proposer’s name been changed, has any other business been purchased and/or has any merger or consolidation taken place:
    Does the proposer currently have Medical Malpractice or Professional Indemnity Insurance in force for the activities for which cover is being sought:
    If Yes please provide
    Has any proposal for similar insurance made on behalf of you, your business, any predecessor of the business, or any partner or director ever been declined or has such insurance ever been cancelled, renewal refused or any special terms or excess imposed (other than general market increases):
    After full enquiry have you sustained any loss through the fraud or dishonesty of any person
    After full enquiry are you aware of any fraud, dishonesty, bankruptcy or administration order applicable to any past or present partner, director or employee:
    After full enquiry, have you, any partner, director, employee or contractor ever been convicted of a criminal offence?
    After full enquiry, has any claim for malpractice, negligence or breach of professional duty been made against you, you business or any partner, director, employee or contractor whilst in this or any other business?
    After full enquiry are you aware of any circumstance or incident which has or could result in any claim being made against you, your business, or any partner, director, employee or contractor whilst in this or any other business:
    After full enquiry have you, any partner, director, employee or contractor been subject to any disciplinary proceedings or actions for misconduct in a professional respect whilst in this or any other business?
    After full enquiry have you, any partner, director, employee or contractor ever been the subject of a complaint to a regulator (ie AHPRA, HCCC, etc), which required a response:
    section 8
    Declaration
    I, the undersigned duly authorised person(s) declare that:
    1. I am the Proposer named on this Proposal Form; and
    2. the above statements are correct, true and complete; and
    3. no information material to this Proposal Form has been withheld; and
    4. I have read the important facts which you have put before me and I understand the advice given in relation to the duty of disclosure; and
    5. I have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and
    6. I understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and
    7. I undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
    8. I acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me in relation to this insurance.