NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance

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1 NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance Brokers Ltd have arranged an insurance policy designed to provide you, registered psychologists who are financial members of the Society, with insurance protection for claims laid against you in respect of any civil liability arising from a breach of your professional duty. The reason you need insurance is that, it not only provides financial assistance to pay damages awarded against you, but also provides for the costs of defending yourself against allegations, which may not be justified. In addition General Liability Insurance cover is included which provides $2,000,000 (in the aggregate) indemnity. BENEFITS The policy provides you with retroactive cover to the date on which you became a member of the Society. This means that if a claim is first made known to you after the time of joining the insurance scheme, and is notified to the insurer before the current years expiry date of the policy, even though the incident may have arisen out of work you did a year or two before, providing it is after you joined the Society, you will have insurance protection. Free cover is available to intern students who are student members of NZ Psychological Society whilst working with a current insured member of the Society. This is subject to completion of a proposal and subject to the insured intern taking up cover once they have graduated. Free access to Employee Assistance Programme services up to the value of $500 per session with a maximum of four sessions in the event of a claim. Free legal advice for up to $1,000 with DAC Beachcroft through the 0800 Helpline. Nil excess for your Insurance cover. Two Reinstatements Additional covers are also available and a summary of the packages available and the premiums are set out below. BASE INSURANCE PACKAGE Insurance & Public Liability Insurance Summary of Cover Provides protection for any claim in respect of a civil liability incurred as a result of the provision of or failure to provide professional healthcare services in the conduct of your profession, a registered psychologist. The policy also covers defence costs incurred in relation to any claim; such defence costs shall be part of and not in addition to the limit of indemnity of the policy. General Liability Summary of Cover Provides cover for all amounts you become legally liable to pay for compensation in respect of personal injury or property damage that is caused by an occurrence in connection with your business and happens during the period of insurance.

2 OPTIONAL INSURANCE PACKAGE 1 Employers and Statutory Liability Insurance Employers Liability Provides $500,000 indemnity cover for civil claims brought by employees against the employer for grievances outside the Accident Compensation and Rehabilitation Insurance Act or Accident Insurance Act, for any claims occurring and reported during the policy period. Statutory Liability Provides $500,000 indemnity cover for any breach or alleged breach of Strict Acts of Parliament including costs of investigation, any fines or penalties awarded, and legal defence costs, for any claims occurring and reported during the policy period. Note: for a breach under the Health & Safety in Employment Act defence costs and reparation costs only. OPTIONAL INSURANCE PACKAGE 2 Management Liability (for a Business/Practice with many different Practitioners) Directors and Officers Cover Provides indemnity following a wrongful act committed by the directors or officers of a company Employment Disputes Cover Provides legal defence costs and awards in respect of damages, claims made by employees Internet Liability Provides cover for liability exposures arising out of your activities on the internet or Fidelity Guarantee Provides cover for losses due to dishonesty of your employees OPTIONAL INSURANCE PACKAGE 3 Cyber Liability

3 Policy BASE INSURANCE PACKAGE Insurance & General Liability Insurance Summary of Cover Limit any one Claim Limit in the Aggregate Excess $250,000 $500,000 Nil Premium (incl. GST) Full Year from 18/10/2014 Premium (incl. GST) Half Year from 18/04/2015 Premium (incl. GST) Quarter Year from 18/07/2015 $404 $283 $222 $500,000 $1,000,000 Nil $1,000,000 $2,000,000 Nil $2,000,000 $4,000,000 Nil $439 $300 $231 $519 $340 $251 $657 $409 $285 Policy OPTIONAL INSURANCE PACKAGE 1 Employers and Statutory Liability Insurance Limit (Any One Claim Excess and in the Aggregate) Employers Liability $500,000 $500 Statutory Liability $500,000 $500 Annual Premium (incl. GST) $46 Policy Directors and Officers Liability OPTIONAL INSURANCE PACKAGE 2 Managemnet Liability Insurance Limit (Any One Claim and Excess in the Aggregate) $250,000 Employment Disputes $50,000 Internet Liability $250,000 TBA Annual Premium (incl. GST) Please address your enquiry to Fidelity Guarantee $50,000 OPTIONAL INSURANCE PACKAGE 3 Cyber Liability Insurance Policy Excess Annual Premium (incl. GST) Cyber Liability (Contact us for more information - Premium shown is subject to proposal) $100,000 TBA $102.80

4 Malpractice & Public Liability Proposal For members of the NZ Psychological Society arranged by Rothbury - Wilkinson Insurance Brokers Southern Pacific Underwriting Agency Ltd, Level 9, 81 Molesworth Street, Thorndon, Wellington 6011 P. O. Box 11641, Manners Street, Wellington 6142 This policy is subject to the policy holder being a Registered Psychologist and a current financial member of the Society and solely covers the policy holder. It is important that all questions are answered fully. Where there is insufficient space please attach additional information to this proposal. Applicant details Name of member: Practice name (if different): Postal address: Phone no: Inception date of continuous membership of the Society (retroactive date): Medical Malpractice cover (this package automatically includes $2,000,000 Public Liability cover) Limit of Liability: $250,000 any one claim; $500,000 maximum per year $500,000 any one claim; $1,000,000 maximum per year $1,000,000 any one claim; $2,000,000 maximum per year $2,000,000 any one claim; $4,000,000 maximum per year If you wish to add additional cover to your base insurance package please refer to the optional package attachment. This insurance package is designed to provide cover for the following activities: The provision of psychological services including clinical psychology, industrial/organisational psychology, educational psychology, community psychology, counselling psychology, kaupapa Māori psychology, health psychology, social psychology, sports psychology, neuropsychology, criminal justice and forensic psychology, developmental and child psychology, coaching, training, supervision, research, and specialist report writing for the family court. It also includes student members under guidance. If you wish to extend your policy to cover activities in addition to the above please give details below (additional premium may apply): Annual turnover related to this activity (Current Year): $ Estimated Annual turnover related to this activity (Next Year): $ Statutory Liability and Employers Liability cover Statutory Liability: $500,000 Limit of Liability Employers Liability: $500,000 Limit of Liability Please provide the following details in respect of all current staff Name qualifications Year qualified Number of years as a member Claims history Have you or any other person who is to be covered under this insurance ever had any insurance declined or cancelled, renewal refused, special conditions imposed; excess imposed or claim rejected? If Yes please provide details below. Yes No Have you or any other person who is to be covered under this insurance ever been the subject of disciplinary proceedings for professional misconduct, including Health & Disability Commission investigations? If Yes please provide details below. Yes No Are you or any other person who is to be covered under this insurance, after enquiry, aware of any claims or circumstances which might result in claims against you or any other person who is to be covered under this insurance? If Yes please provide details below. Yes No 09/14 Medical Malpractice Proposal Page 1 of 2

5 Declaration: On behalf of all proposed Insureds I/We declare and agree that: (a) all information provided, in this proposal or attachments, is true and complete in every respect and that no Material Facts remain undisclosed; (b) if this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance; (c) I/We understand that SPUA requires this information in order to evaluate this proposal and that the Privacy Act 1993 entitles me/us to have access to, and request the correction of, any information retained; (d) SPUA is authorised to disclose information to its advisers, reinsurers, other insurers and parties with a financial interest in the subject matter of this proposal; (e) SPUA is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access on behalf of Lloyd's Underwriters; (f) SPUA is authorised to obtain from other parties any information which may be relevant to the acceptance of this risk ; (g) the signing of this proposal does not bind either party to complete the contract and that no cover will be in force until confirmed by SPUA. Insured(s) signature: Date: / / 09/14 Medical Malpractice Proposal Page 2 of 2

6 OTHER INSURANCE COVERS AVAILABLE Rothbury-Wilkinson Insurance Brokers can also provide no obligation and competitive quotes for the following insurance covers: Life Trauma Income Protection Total & Permanent Disability Group Life / Medical Medical Insurance Kiwisaver Home Contents Private Motor Vehicle Travel Material Damage Business Interruption Cyber Liability Payment Details Premium calculation (per Psychologist, as per above): Number of Psychologists in Practice: Optional Insurance Package 1 TOTAL PAYABLE Cheque enclosed for fee due as above made payable to New Zealand Psychological Society Direct Credit to NZ Psychological Society Inc. Bank Account No Deposit Date: Credit Card payment (VISA or Mastercard only) Card No: Cardholder Name: Expiry Date / Signature: Return completed proposal, with payment to NZPsS, PO Box 25271, Featherston St PO, Wellington 6146

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