Application for Membership and Insurance

I wish to apply for Membership of MDA National Limited and a Professional Indemnity Insurance Policy underwritten by MDA National Insurance. If my Membership application is accepted I agree to be bound by the Constitution of MDA National and I undertake to contribute to the assets of MDA National, such amount as may be required, up to $10, if MDA National is wound up while I am a Member or within one year afterwards.

I declare that:

1. I agree to be bound by the terms and conditions of the policy.
2. I have read and understand the important notice and contents of this proposal and acknowledge that the information included in, or attached to, this form is accurate and complete.
3. I understand my duty of disclosure exists until the contract of insurance is entered into and that I have continuing obligation to inform MDA National Insurance of any material alteration of the risk during the period of insurance including any material change in the nature of the services provided by me.

Consent

4. I consent to MDA National and MDA National Insurance and any companies, firms or individuals who assist them in providing services including but not limited to reinsurers, medical specialists, actuaries, accountants, legal advisers and IT contractors collecting, holding, using, disclosing and managing the personal information I provide, in accordance with the MDA National group privacy policy.

Application for Membership and Insurance Policy

I wish to apply for Membership of MDA National Limited and a Professional Indemnity Insurance Policy underwritten by MDA National Insurance. If my Membership application is accepted I agree to be bound by the Constitution of MDA National and I undertake to contribute to the assets of MDA National, such amount as may be required, up to $10, if MDA National is wound up while I am a Member or within one year afterwards.

1. I agree to be bound by the terms and conditions of the policy.
2. I have read and understand the Important Notice and contents of this proposal and acknowledge that the information included in, or attached to, this form is accurate and complete.
3. I understand my duty of disclosure exists until the contract of insurance is entered into and that I have a continuing obligation to inform MDA National Insurance of any material alteration of the risk during the period of insurance including any change in my field of practice or any material change in the nature of professional services provided by me or the risk category that I have previously declared.
4. I acknowledge that the policy (if issued) will not indemnify me with respect to:
   1. claims that have been made against me as at the date of this proposal
   2. claims that arise in the future from matters that I should reasonably be aware of as at the date of this proposal will likely give rise to a claim.
   3. any current investigation or inquiry
   4. any future investigation or inquiry that results from a matter that has been or is currently being investigated, as at the date of this proposal and
   5. any matters reported on or with this proposal or matters that should have been reported on or with this proposal.

Authorisation and consent

5. I authorise and request any Medical Board or other registration body to release all information requested by MDA National Insurance. This includes information regarding:
   1. my registration as a medical student or medical practitioner
   2. any conditions placed upon it
   3. any complaints, investigations or hearings by the Medical Board or registration body involving me whether or not there has been a final resolution.

I also consent to the disclosure of such information to MDA National Insurance and any of its reinsurers or advisers, as appropriate

6. I authorise and request my former insurer or indemnity provider to release all information requested by MDA National Insurance regarding any previous policies held by me. This includes details regarding any
   1. requests for indemnity under the policy
   2. assistance for claims, complaints, investigations, inquiries involving me or any other matters for which I have claimed under the Policy whether or not there has been a final resolution and irrespective of the costs incurred.
   3. non standard terms or conditions imposed on any previous policies held by me.
   4. cancellation of a policy held by me
   5. refusal to make an offer of insurance
   6. default in my payment history

7. I consent to the disclosure of such information to MDA National Insurance and any of its reinsurers or advisors as appropriate.
8. I consent to MDA National Insurance and any companies, firms or individuals who assist them in providing services including reinsurers, medical specialist, solicitors and barristers holding and using the information I provide, in accordance with the MDA National Group Privacy Policy.
9. I authorise MDA National Insurance to debit my nominated credit card number for the payment of my Membership subscription and indemnity insurance premium for the amount shown in the payment options section of this form.

I wish to apply for Membership of MDA National Limited and a Professional Indemnity Insurance Policy underwritten by MDA National Insurance. I agree to be bound by the Constitution of MDA National Limited, including an agreement to contribute such amount as may be required, up to $10, to its assets while I am a Member or within one year afterwards.

I declare that:

1. I have been provided with access to the Financial Services Guide (FSG), Product Disclosure Statement (PDS) and Policy Wording and I agree to be bound by the terms and conditions of the policy.
2. I have read and understand the Important Notice and contents of this proposal and acknowledge that the information included in, or attached to, this form is accurate and complete.
3. I will provide evidence of my Gross Annual Billings to MDA National Insurance if requested to do so.
4. If I apply and am eligible for the Premium Support Scheme (PSS), I agree to comply with my obligations under the Scheme.
5. I understand my duty of disclosure exists until the contract of insurance is entered into and that I have a continuing obligation to inform MDA National Insurance of any material alteration of the risk during the period of insurance including any change in my field of practice or any material change in the nature of professional services provided by me, or the risk category or billings bands that I have previously declared.
6. I acknowledge that the policy (if issued) will not indemnify me with respect to:
   1. claims that have been made against me as at the date of this proposal
   2. claims that arise in the future from matters that I should reasonably be aware of as at the date of this proposal will likely give rise to a claim
   3. any current investigation or inquiry
   4. any future investigation or inquiry that results from a matter that has been or is currently being investigated, as at the date of this proposal
   5. any matter reported on or with this proposal or matters that should have been reported on or with this proposal

Authorisation and consent:

7. I authorise and request any Medical Board or other registration body to release all information requested by MDA National Insurance regarding my registration as a medical practitioner, any conditions placed upon it and any complaints to, or investigations or hearings by the Medical Board or registration body involving me whether or not there has been a final resolution and I consent to the disclosure of such information to MDA National Insurance and any of its reinsurers or advisers, as appropriate.
8. I authorise and request my former insurer or indemnity provider to release all information requested by MDA National Insurance regarding any previous policies held by me. This includes details regarding any:
   1. requests for indemnity under the policy
   2. assistance for claims, complaints, investigations, inquiries involving me or any other matters for which I have claimed under the Policy whether or not there has been a final resolution and irrespective of the costs incurred
   3. non standard terms or conditions imposed on any previous policies held by me
   4. cancellation of a policy held by me
   5. refusal to make an offer of insurance
   6. default in my payment history.
9. I consent to the disclosure of such information to MDA National Insurance and any of its reinsurers or advisors as appropriate.
10. I consent to MDA National an MDA National Insurance and any companies, firms or individuals who assist them in providing services including reinsurers, medical specialists, solicitors and barristers, holding and using the information I provide, in accordance with the MDA National Group Privacy Policy.

11. I hereby authorise MDA National Insurance to provide the information, as stated in the disclosure information section, to any person providing my privacy disclosure password to MDA National Insurance.
12. I am aware that it is my responsibility to keep my password confidential and that MDA National Insurance will not be responsible to verify that any person using my password has been properly authorised by me to do so.
13. I may revoke this authorisation in writing at any time. I may also change my password at any time by contacting MDA National Insurance.