Important Notice

Completing this Proposal Form does not mean that you will automatically be granted insurance cover proposed. However, if insurance is granted, it will be based upon representations you give us. Should any particulars given have changed or be incorrect you must notify us immediately. We reserve the right to revise or withdraw any insurance granted at any time subject to any changes in such particulars.

Duty of Disclosure

Before you enter into a contract of general insurance with an Underwriter, you have a duty, under the Insurance Contracts Act 1984, to disclose to the Underwriter 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 any matter:

• that diminishes the risk to be undertaken by the Underwriter;
• that is of common knowledge;
• that your Underwriter knows or, in the ordinary course of its business, ought to know;
• as to which compliance with your duty is waived by the Underwriter.

It is important that all information contained in this proposal is understood by you and is correct, as you will be bound by your answers and by the information provided by you in this proposal. You should obtain advice before you sign this proposal if you do not properly understand any part of it.   Your duty of disclosure continues after the proposal has been completed up until the contract of insurance is entered into.

Non –Disclosure

If you fail to comply with your duty of disclosure, the Underwriter 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 Underwriter may also have the option of avoiding the contract from its beginning.

Change of Risk or Circumstances

You should advise Horsell Duffy Langley as soon as practicable of any material change to your normal business as disclosed in the proposal, such as changes in location, acquisitions and activities.

Privacy Statement

We are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Enhancing Privacy Protection) Act 2012. This sets out basic standards relating to the collection, use, storage and disclosure of personal information.

Our Privacy Policy, available at www.HDLbrokers.com.au or by calling us, sets out how:

• we protect your personal information;
• you may access your personal information;
• you may correct your personal information held by us;
• you may complain about a breach of the Privacy Principles or Registered Privacy Code and how we will deal with such a complaint.

We need to collect, use and disclose your personal information in order to consider your application for insurance and to provide the cover you have chosen, administer the insurance and assess any claim. You can choose not to provide us with some of the details or all of your personal information, but this may affect our ability to provide the cover, administer the insurance or assess a claim.

We may disclose your personal information to third parties who assist us in providing the above services. These parties (which include our related entities, distributors, agents, insurers - including reinsurers - and service providers) will only use the personal information for the purposes we provided it to them for (unless otherwise required by law).  It is likely that the information will be disclosed overseas.

Information will be obtained from individuals directly where possible and practicable to do so. Sometimes it may be collected indirectly (e.g. from your representatives or co-insured’s).   If you provide information for another person you represent to us that:

• you have the authority from them to do so and it is as if they provided it to us;
• you have made them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it. If it is sensitive information we rely on you to have obtained their consent on these matters. If you have not done or will not do either of these things, you must tell us before you provide the relevant information.

You are entitled to access your information if you wish and request correction if required. You may also opt out of receiving materials sent by us by contacting Horsell Duffy Langley.

Healthcare Services Specialisations

Anaesthesia

Bariatric Surgery (Includes work in the GENERAL SURGERY specialisation but also includes Bariatric procedures)

Cardiology - Interventional (Includes work in CARDIOLOGY - NON-INTERVENTIONAL specialisation but also includes interventional procedures)

Cardiology - Non-Interventional (Excludes any interventional procedures)

Cardiothoracic Surgery

Colorectal Surgery

Cosmetic Proceduralist (Practitioners with General Registration only that perform surgical cosmetic procedures)

Dermatology

Emergency Medicine

Endocrine Surgery

Endocrinology

Gastroenterology

General Physician

General Practice - Non-Procedural

(Includes non-procedural work but no anaesthetic, cosmetics or obstetric work)

General Practice – Procedural A (

Includes work in the GP Non Procedural category but also includes procedural work, regional anaesthetic, minor cosmetics but no obstetrics)

General Practice – Procedural B

(Includes work in both the GP Non-Procedural and GP Procedural A categories but also includes general anaesthetic, obstetrics but no surgical cosmetic procedures)

General Surgery

(Excludes any Bariatric procedures)

Genetics

Geriatric Medicine

Gynaecology/IVF

Haematology

Hospital Medical Officer

Immunology And Allergy

Infectious Diseases

Intensive Care

Medico-Legal

Nephrology

Neurology

Neurosurgery

Nuclear Medicine

Obstetrics & Gynaecology

Occupational Medicine

Oncology

Ophthalmology - Non-Procedural

(Excludes any surgical procedures)

Ophthalmology - Procedural

(Includes work in the OPHTHALMOLOGY - NON- PROCEDURAL specialisation but also includes surgical procedures)

Oral & Maxillofacial Surgery

Orthopaedic Surgery

(Excludes any neck or spinal procedures)

Orthopaedic Surgery – Incl. Spinal and Neck

(Includes work in the ORTHOPAEDIC SURGERY specialisation but also includes any neck or spinal procedures)

Otolaryngology (Surgery)

Paediatric Surgery

Paediatrics

Pain Management

Palliative Care

Pathology

Pharmacology

Plastic & Reconstructive Surgery

(Excludes any cosmetic procedures)

Plastic, Reconstructive And Cosmetic Surgery

(Includes work in the PLASTIC & RECONSTRUCTIVE SURGERY specialisation but also includes any cosmetic procedures)

Psychiatry

Public And Community Health

Radiation Oncology

Radiology

Rehabilitation

Respiratory Medicine

Rheumatology

Sports Medicine

Ultrasound - Diagnostic

Urology

Vascular Surgery