1 FINANCIAL & PROFESSIONAL SERVICES AUSTRALIAN TRADITIONAL MEDICINE SOCIETY LTD MEDICAL MALPRACTICE (INCLUDING PUBLIC & PRODUCTS LIABILITY) IMPORTANT INFORMATION AND RENEWAL APPLICATION Before you choose to arrange insurance, please read the important information in this document and contact Marsh Pty Ltd (Marsh) immediately if you have any question. RENEWAL APPLICATION 1. Please answer all questions fully, leaving no questions unanswered. 2. If you have insufficient space to answer questions, please attach additional information on a separate page. 3. Completion of this Application does not bind you or insurers to complete this insurance. Insurance cover will not be in place until acceptance is confirmed by the insurer in writing. 1. Name: Mr Mrs Ms Miss Telephone: Business: Private: Mobile: Fax: Your Company/Business/Trading Name(s) (if applicable) Your ABN (if applicable) 2. Postal Address: Postcode: 3. Business Address: (i) Postcode: (ii) Postcode: Please note: Mobile Work is automatically covered within this policy. 4. Profession: 5. ATMS Membership No: OFFICE USE ONLY Accredited Modalities: Policy Inception: Payment Method: Basse Premium:
2 6. Practising personnel. Please supply total numbers of: (i) Partners of the business to be covered by this policy * (not including yourself) (ii) Employees who are Practitioners. (and are not sub contractors). * * Provide full details of the Partners and Employees (who are practitioners) to be covered by this policy, including their name, and Modalities/ Activities. Please attach their qualification certificates if not already done so. 7. Limit of Indemnity: $1,000,000 $2,000,000 $5,000,000 $10,000,000 $20,000,000 If you are a member of the Chinese Medicine Board of Australia their minimum requirement is $5,000, A $10,000,000 Public & Products Liability is automatically included. Should you require a $20,000,000 Public & Products Liability limit, Please contact us for a quotation. 8. Gross Income. Please tick the approximate amount of Gross Income obtained in the last financial year by the Practising Personnel noted in Question 1 and 6. This Gross Income is for the modalities/activities for which cover is required. If you are a new practitioner please state your estimated Gross Income for your first year. $0 to $10,000 $10,001 to $100, ,001 to $200,000 If over $200,001 Provide estimate: $ 9. Have you completed any courses or require cover for any new modalities since you last applied for this Insurance, which you have not already notified to us. If yes please advise the modality/activity and provide Qualification Certificate YES NO 10. Do you comply with the ATMS Code of Conduct when practicing ATMS accredited and non accredited modalities activities? YES NO 11. Modalities/Activities This policy will only cover the modalities/activities you have listed below, for which you are qualified in, subject to insurer s agreement. If there is not enough room please complete on a separate page. 12. Do you own and/or operate a school or college? (This does not include Seminars or workshops) YES NO If yes, please request a School/College application form. This activity is not covered unless agreed by insurers, and an additional premium paid. 13. Are you currently, or have you ever been, insured for Medical Malpractice and Public & Products Liability Insurance? YES NO If yes, please advise name of Insurance Company and the expiry date. 14. Have any claims ever been made against you, or your practice, within the last 5 years? YES NO If yes, please complete Question 17 below. 15. Are you and/or your staff, after enquiry, aware of any circumstances which may result in any claim being made against you or your practice? YES NO If yes, please complete Question Marsh Australian Traditional Medicine Society Ltd
3 16. Has any Insurer ever cancelled, declined, refused to renew, or accepted only on special terms, your medical malpractice (including Public & Products Liability) Insurance? YES NO If yes, please complete Question Have you or your practice or a staff member ever been subject to disciplinary proceedings for professional misconduct? YES NO If yes, please complete Question Claims or Circumstances a. Date matter notified to insurers or insurance brokers Date: b. Name of claimant or potential claimant D D M M Y Y c. Brief description of matter d. Estimated loss or possible loss e. Is the matter finalised or outstanding (please tick) Finalised Outstanding DECLARATION You must sign the declaration below once agreed. If there is no signature your application will not be accepted. I/We have read and understood the important notices on pages 1 & 2 of this application. I/We declare that all answers and statements made in this application are true, correct and complete in every aspect. I further agree to the Terms of Engagement enclosed with this application. I recognise your privacy obligations and would like you to issue my insurance policy to the Australian Traditional Medicine Society. Signed: Please tick if you do not want your insurance policy/details sent to the ATMS Date: D D M M Y Y Signing of this Declaration does not bind you or the insurers to complete the insurance, however cover will not incept without a recently signed and dated application and acceptance is confirmed by the insurer in writing. Marsh Australian Traditional Medicine Society Ltd 3
4 HOW TO PAY WE DO NOT ACCEPT PAYMENT BY MONEY ORDER OR CASH PAYMENT: Please refer to the Premium tables below. The premium is determined by your gross income, the limit of indemnity you selected in questions 7 & 8 and the State/Territory in which you reside. If you are paying by cheque, please make it payable to Marsh Pty Ltd and attach it with your application OR fill out the credit card payment form on the last page. Send back to Marsh via: Fax: Mail: PO Box H176, Australia Square, SYDNEY NSW 1215 PREMIUM The premiums quoted are for the period 4:00 p.m. on 1 March 2013 to 4:00 p.m. 31 March 2013 provided we receive your payment by 31 March STATE $1 million limit $2 million limit $5 million limit $10 million limit $20 million limit If your Gross income is between $0 - $10,000 you will pay the following premium: NSW/QLD $93.04 $ $ $ $ VIC/TAS/NT/ WA $95.12 $ $ $ $ ACT $94.29 $ $ $ $ SA $95.53 $ $ $ $ If your Gross Income is between $10,001 - $100,000 you will pay the following premium: NSW/QLD $ $ $ $ $ VIC/TAS/NT/ WA $ $ $ $ $ ACT $ $ $ $ $ SA $ $ $ $ $ If your Gross Income is between $100,001 - $200,000 you will pay the following premium: NSW/QLD $ $ $ $ $ VIC/TAS/NT/ WA $ $ $ $ $ ACT $ $ $ $ $ SA $ $ $ $ $ All amounts include a document charge of $45.00, GST and stamp duty. The variations in premiums are due to different stamp duties for each State and Territory. CREDIT CARD PAYMENT FORM Client Details Name on Card: Mr Mrs Ms Miss Business: Private: Mobile: Fax: Card Type: / / / Expiry: / Cardholder Signature: Amount: $ Not to exceed $10,000. Amount charged includes a 0.9% Administration Fee I hereby authorise Marsh Pty Ltd to deduct the amount indicated above from my credit card and I understand that an administration fee of 0.9%, inclusive of GST, will be charged on the value of this transaction, when I pay by credit card. OFFICE USE ONLY Date: Account Name: Client code: Invoice No: 4 Marsh Australian Traditional Medicine Society Ltd
5 IMPORTANT NOTICES Before you instruct us to arrange your insurance, please read these important notices which: Outline your rights and obligations in relation to entering into a contracts of general insurance Provide details of who to contact at Marsh should you have any problems with our services Detail how we manage your personal and private information If you have any questions, or need to make a further declaration, please contact Marsh. DISCLOSURE Your Duty of Disclosure - contracts of general insurance subject to the Insurance Contracts Act 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 the 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 matters: That diminish the risk to be undertaken by the insurer That are of common knowledge That your insurer knows or, in the ordinary course of its business, ought to know, or 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, 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. Please note that your duty to disclose applies also when you amend, alter, vary or endorse a policy. DISCLOSURE SUBSIDIARY & ASSOCIATED COMPANIES Your Duty of Disclosure - Cover which is arranged for subsidiary and/or associated companies in addition to named insureds. If you enter into a contract of insurance on behalf of any subsidiary and/or related company of the named insured, that subsidiary and/ or related company has the same duty of disclosure as the named insured. We recommend that you ensure that each subsidiary and/or related company is made aware of the duty of disclosure and given an opportunity to make any necessary disclosures. UTMOST GOOD FAITH Every insurance contract is subject to the doctrine of utmost good faith, which requires that parties to the contract should act toward each other honestly and fairly, avoiding any attempt to deceive in assuming and performing contractual obligations. Failure to do so on the part of the insured may permit the insurer to refuse to pay a claim or to cancel the policy or both. ESSENTIAL READING OF POLICY WORDING We will provide you with a copy of the insurers standard policy wording at the time of providing you with quotation/s. It is essential that you review this wording to confirm that it meets with your requirements. We will also provide you with a full copy of your policy as soon as it is received from the insurer. Again it is essential that you read this document without delay and advise Marsh Pty Ltd in writing of any aspects which are not clear or where the cover does not meet with your requirements. CHANGE OF RISK OR CIRCUMSTANCE It is vital that you advise the insurer of any changes to your company s usual business. For example, insurers must be advised of any: Mergers or acquisitions, Changes in occupation or location, New products or services, or New overseas activities. If you are in doubt as to whether to notify your insurer of a change in business operations, please consult Marsh. Please note that your duty to disclose applies also when you amend, alter, vary or endorse a policy. SUBROGATION Some policies contain provisions that either exclude or reduce the insurer s liability for a claim if you waive or limit your rights to recover damages from another party in relation to any loss. You may prejudice your rights with regard to a claim if, without the prior agreement from your insurers, you make any agreement with a third party that will prevent the insurer from recovering the loss from that, or another party. If you have such agreements, we may be able to negotiate with the insurer to permit them and therefore we request you advise Marsh of their existence. Examples of such agreements are the hold harmless clauses which are often found in leases, in maintenance or supply contracts from burglar alarm or fire protection installers and in repair contracts. If you are in doubt, please consult Marsh. Marsh Australian Traditional Medicine Society Ltd 5
6 PRIVACY NOTICE Marsh Pty Ltd ( Marsh ) and the insurers that Marsh place your insurance with ( Insurer ) are bound by the requirements of the Privacy Act 1988 as amended by the Privacy (Private Sector) Act 2000 ( the Act ), which sets standards on the collection, use, disclosure and handling of personal information. Personal information is essentially information about individuals where the individual can be identified. It may include information such as your name, contact details, age, insurance history or financial details. Sensitive Information is a particular kind of personal information and includes information about an individual s health; racial or ethnic origins; membership of political, professional or trade associations; political opinions or philosophical or religious beliefs; criminal record; or sexual preferences. Marsh and your insurers disclose personal information to third parties both in Australia and overseas, where it is believed necessary for us to provide our services to the professional standard you expect. These parties may include (but are not limited to) insurers, reinsurers and other intermediaries. All parties may also disclose this information, as needed, to employers, health workers, investigators, lawyers, loss adjusters and to government departments if required by law to do so. Where practical, information will be collected from individuals directly, however sometimes it may be collected indirectly by way of a representative. When you give Marsh or your Insurer personal information about other individuals, we rely on you to have made them aware that you will or may provide their information to us, the purposes for which we use it, the types of third parties we disclose it to and how they can access it (as described in this notice). If it is sensitive information we rely on you to have obtained their consent to these matters. If you have not done these things, you must tell us before you provide the relevant information. Where required you can access the personal information you provided to Marsh, and we can also facilitate you accessing the information supplied to your insurers through us by contacting: The Privacy Officer Marsh Pty Ltd PO Box H176 Australia Square NSW ABN: Tel: WHAT SHOULD I DO IF I HAVE A COMPLAINT? 1. Contact us and tell us about your complaint. We have our own internal complaints handling procedure, a copy of internal complaints handling procedure, a copy of which is available upon request. In the first instance you should address any concern or complaint to the Marsh representative servicing your account. Alternatively you may contact us either by or telephone the Marsh Complaints Officer on (03) If your complaint is not resolved to your satisfaction, we will handle the matter under our internal complaints handling process. Either a manager of the business unit which is the recipient of the complaint &/or the Marsh Complaints Officer will investigate your complaint and take appropriate action. You will be advised within 15 working days of our decision. If the matter is complex and a longer period is required you will be informed. 3. We are a member of an external dispute resolution scheme. If your complaint cannot be resolved to your satisfaction by us you have the right to refer the matter to the free consumer service offered by these schemes. THE FINANCIAL OMBUDSMAN SERVICE LIMITED (FOS) You may be able to refer your complaint to the FOS which is a national scheme for consumers aimed at resolving disputes between clients and their broker or insureds and their insurance companies or claimants who have a dispute with another person s insurance company in relation to motor vehicle property (i.e. third party) claim. The FOS also provides advice and other information about general insurance matters. If you have any query about whether your complaint can be handled by FOS, call or CLAIMS MADE DURING THE PERIOD OF INSURANCE The insurance being proposed for provides cover on a claims made basis. This means that claims first made against you AND reported to the insurer during the period of insurance are covered irrespective of when the act causing the claim occurred, subject to the provisions of any clause/s relating to a retroactive date (see Notice below titled Retrospective Cover ). Please note the effect of Section 40(3) of the Insurance Contracts Act If you become aware of facts that may give rise to a claim, and you give written notice to the insurer of those facts as soon as possible (and before the policy period expires), then the insurer may not deny liability for that claim, when made, solely because it was made after the expiry of the policy period. For this reason, you must advise the insurer in writing of all incidents that may give rise to a claim against you without delay after such incidents come to your attention and prior to the policy s expiry date. RETROSPECTIVE COVER The insurance being proposed for does not provide cover in respect of claims arising out of acts committed prior to any Retroactive Date specified in the policy wording unless you specifically request and obtain this cover. An additional premium may apply to any extension to the retroactive date. UNDERWRITING BINDER The insurances being proposed for are placed with an insurer who has given to us an authority to effect the contract of insurance with you as its agent and not yours. 6 Marsh Australian Traditional Medicine Society Ltd
7 REMUNERATION AND TERMS OF ENGAGEMENT Please read, and make certain that you understand, the following. REMUNERATION Marsh s remuneration in relation to the services as set in our Terms of Engagement below is by way of a commission received from the insurer and a document fee of $49.50 incl GST TERMS OF ENGAGEMENT We confirm we offer our services to you on the following terms: You will give us all information and instructions required by us in arranging a contract of insurance. Our services relate solely to the policy/ies of insurance noted in our letter communicating the recommended program to you. In arranging your insurance cover, Marsh act under a binder agreement on behalf of W.R. Berkley Insurance Australia (W.R. Berkley) and not for you. This means that W.R. Berkley has given Marsh the authority to effect insurance on W.R. Berkley s behalf and that we have not approached the insurance market for alternative quotes or conducted a revised assessment of your insurance requirements. In the event of a claim, we will act as your agent and we will assist you in dealing with W.R. Berkley on any claim settlements. We make every effort to correctly determine the premium, fire services levy (if applicable), GST and any other government charges, taxes, fees or levies that apply to your insurance. However, occasionally errors can occur. We may correct any such error and (except to the extent prohibited by law) we will not be responsible for any loss you suffer as a result of the error and its correction. You are responsible for the accuracy of all information given to the insurer and/or us in respect of any contract of insurance entered into. Any non-disclosure or misrepresentation may prejudice your right to make a claim under your policy/ies. In no event will Marsh and/or its authorised representatives be liable for any indirect, special, consequential or punitive damages or for any lost profits arising out of or relating to any financial services provided by Marsh and/or its related bodies corporate and affiliates and their representatives (including but not limited to their employees, agents, consultants and authorised representatives (collectively the Relevant Persons ). The aggregate liability of Marsh and the Relevant Persons combined, arising out of or relating to the provision of our financial services shall not exceed $5,000,000. This provision applies to the fullest extent permitted by applicable law for all events giving rise to any liability on our part whether arising in contract, tort (including negligence) or on any other basis, but does not apply (a) to any liability arising as a result of the fraud or wilful misconduct of Marsh and/or its authorised representatives or (b) in relation to any services supplied to you as a Retail Client as that term is defined in Chapter 7 of the Corporations Act 2001 (Cth). We will only place an insurance risk with an insurer authorised by the Marsh Market Information Group. However, we cannot and do not guarantee the solvency or continued solvency of any insurer. Where we advise you of an insurer s Standard & Poors (or equivalent) credit rating this does not apply in relation to any insurances arranged for you as a Retail Client as that term is defined in Chapter 7 of the Corporations Act 2001 (Cth). If there is a refund of premium owed to you as a result of a cancellation to a policy, the premium, fire services levy (where applicable), GST and any other government charges, taxes, fees or levies will be returned to you on a pro rata basis excluding any fee and/or commission charged/ earned which is deemed to be fully earned by us on placement of the policy. Either of us may terminate these terms of engagement by giving the other party fourteen (14) days written notice. On receipt of your notice of termination, we will immediately stop acting as your agent when assisting you in claim settlements. Because we earn our remuneration for arranging your insurance, we both agree no refund of brokerage or fee will be due to you on termination of our appointment. Unless advised otherwise we will forward all correspondence and policy documentation to the postal address that you last provided to us as your correct contact details for the receipt of policy notices and information. The postal address is the only official contact details on which we rely. It is your responsibility to ensure that these details are accurate and complete. We may communicate with you by electronic means, including sending s sending renewal notices and policy documentation via to the address you have provided to us on the new business application form. If you do not want us to send documents to this address either permanently or for a certain period of time (for example when the recipient of the s goes on leave), you have to inform us in writing We will retain the interest (if any) earned from the premium paid by you while it is in our trust account. Marsh Australian Traditional Medicine Society Ltd 7
8 FREQUENTLY ASKED QUESTIONS Q. Can I or fax my application to Marsh? A. Yes you can as long as the copy we receive is legible. The address is and the fax no. is As we have only one fax line at renewal time this line can be very busy. Q. How long does my application form take to be processed? A. It depends what time of the year you apply for your policy but generally we can process your application within a couple of days of receipt. The policy will always be processed from the date we receive the application, unless otherwise requested. Please note that we are unable to backdate cover. Q. I would like to add a new address to my policy how do I do this? A. All changes to your policy must be advised in writing; , fax or post is accepted. Q. I have just qualified in a new modality. How do I add this to my policy? A. Please , fax or post a copy of your qualification to us. This does not need to be sign by a JP. Generally there is no additional charge to add a new modality but the qualification needs to be approved by ATMS. Q. I need to increase my limit of indemnity. How do I do this? A. Please send us a request in writing confirming what limit of indemnity you would like. We will arrange for a quotation for the revised limit of indemnity to be sent to you. Q. I need to change my name or business name. A. Send us a copy of your business certificate of registration or a copy of certificate noting your change in name. Q. Does this policy include cover for plate glass? A. Yes it does. Refer to the policy wording for terms and conditions. Q. Is cover provided for when I attend Trade Fairs, Shows, Markets etc? A. Yes cover is automatically extended to cover these events. Q. Can we pay by cash, money order or American Express? A. No we do not accept either of these methods of payment. We only accept Visa, Mastercard, a cheque or an electronic fund transfer. You will need to call us for electronic transfer details. Q. Will my policy run for 12 months? A. It depends. The scheme has a common renewal date of 01st October. If you start or renew your policy with effect from 01 October your policy will run for 12 month, otherwise, it will be effective from the date the satisfactory application form is received until 01 October. Please note if joining after 01 October premiums are pro-rated each month until June when a short period rate is charged. Q. Does Marsh deal with health funds? A. ATMS deal with all health fund enquires. Contact ATMS on or them at Q. Does my policy cover the Public Liability in respect of A-frames outside my premises? A. Yes, cover is provided. Refer to the policy wording for terms and conditions. Q. Is use of equipment covered? A. Use of equipment, in connection with your modalities eg. Laser, Ultrasound, Tens Machine etc. is covered provided you are suitably trained that the equipment is professionally installed, regularly serviced and maintained. Cover as always is subject to the standard policy terms and conditions. Please refer to the policy wording for full conditions regarding laser equipment. Q. Do you require proof of ATMS membership when applying for insurance? A. You do not need to send a copy of your Certificate or receipt of payment. We will check your membership status with ATMS on receipt of your application. Q. Do I need to send a copy of my First Aid Certificate to Marsh? A. No, you do not need to send Marsh a copy of this. About Marsh: Marsh, a global leader in insurance broking and risk management, teams with its clients to define, design, and deliver innovative industry-specific solutions that help them protect their future and thrive. It has approximately 26,000 colleagues who collaborate to provide advice and transactional capabilities to clients in over 100 countries. Marsh is a wholly owned subsidiary of Marsh & McLennan Companies (NYSE: MMC), a global team of professional services companies offering clients advice and solutions in the areas of risk, strategy, and human capital. With 53,000 employees worldwide and annual revenue exceeding $11 billion, Marsh & McLennan Companies is also the parent company of Guy Carpenter, a global leader in providing risk and reinsurance intermediary services; Mercer, a global 8 leader Marsh in human Australian resource Traditional consulting Medicine and related Society services; Ltd and Oliver Wyman, a global leader in management consulting.