Pharmacy Insurance Quote Request

Your Duty of Disclosure / Misrepresentation
For non-consumer insurance, you must disclose every matter you know, or could reasonably be expected to know, that is relevant to the insurer’s decision to accept the risk and on what terms. This duty continues until cover is agreed and applies again at renewal, variation, extension or reinstatement.

For consumer insurance, you must take reasonable care not to make a misrepresentation.

If you do not comply, the insurer may reduce its liability, cancel the policy, or, in cases of fraud, treat the policy as if it never existed.

Claims Made Policies
Some policies (e.g. professional indemnity) operate on a claims made and notified basis. They generally only cover claims first made and notified during the policy period. You must notify the insurer in writing as soon as reasonably practicable of any claim or circumstance that may give rise to a claim, including before policy expiry.

Occurrence-Based Policies
Policies such as public liability and property insurance generally respond to events occurring during the policy period, even if the claim is made later.

Claims Notification
Notify all claims, losses or circumstances as soon as possible. Do not admit liability, incur costs or settle claims without the insurer’s prior consent.

Changes in Risk
You must inform us of any material changes to your circumstances as required under your policy.

Privacy
We collect and disclose personal information to arrange and administer insurance, assess claims and meet legal obligations. This may include disclosure to insurers and service providers in Australia or overseas. Our Privacy Policy is available on request.

Broker Relationship & Remuneration
We act as your insurance broker. We may receive commission, fees or other remuneration for arranging and servicing your insurance. Details are available on request.

Complaints

If you have a complaint, contact us first. If not resolved, you may refer it to the Australian Financial Complaints Authority (AFCA) at www.afca.org.au

Business details

Name of insured/ Legal entity *

Trading name: *

Address of business premises *

Street address *

City *

State *

Postcode *

Contact Name(s) 1 *

Contact Email Address *

Contact Phone No.

ABN (Optional)

Website

Add another contact? *

YesNo

Contact 2 Name(s)

Contact 2 Email Address

Contact 2 Phone No.

Expiry date of current insurance program (if known)

Number of full-time staff *

Annual turnover (AUD) *

Does the pharmacy provide complex compounding services as defined by the Pharmacy Board of Australia *

YesNo

Building Construction Details

Approx. age of building *

Walls *

Floor *

Roof *

Security

Other

Details of other security

Fire Protection

Choose which fire protection apply to your building *

Smoke detectorsFire extinguishersSprinklers

Other

Details of other fire protection

Insured values

Building

Contents inc fit-out (Note dispensing robots do not need to be individually noted) *

Gross Profit (If unsure, calculation can be made as turn-over minus purchases) *

Stock (please advise maximum levels of stock) *

Cyber questions

Do you have multi-factor authentication on all your devices? *

YesNo

Do you implement encryption on devices and laptops? *

YesNo

Disclosure

Has the business ever been subject to an investigation or inquiry relating to non-compliance with the Pharmacy Board of Australia standards and guidelines? *

YesNo

If yes, please give details *

Have any of the proposes being brought before a professional size society regulatory or registration board for a professional misconduct? *

YesNo

If yes, please give details

In the last 5 years, has the proposed ever been declared bankrupt, or placed in liquidation, receivership or voluntary administration? *

YesNo

If yes, please give details *

Claims

In the last 5 years, has any claim been made against the proposed or any principal, partner, director, consultant or employees in respect to the below policies:

Professional Indemnity & Public Liability *

YesNo

Property *

YesNo

Employment Practices Related *

YesNo

Cyber related *

YesNo

If you have ticked yes to any of the above, please provide details such as date of loss, brief description and settlement amounts *

Are there any circumstances not already notified to insurers, which may give rise to a claim against any entity or individual to be insured by this insurance? Please Note: A ‘circumstance’ (as above) may include any inspection, review, investigation conducted by any authority including (but not limited to) State Health Authorities, Industry Associations or AHPRA. *

YesNo

If yes, please give details.

Declaration of applicant(s)

I confirm that, in providing this information, I am aware of my duty of disclosure to insurers and that:

All information provided is true, complete, and correct to the best of my knowledge.
I am authorised to make this declaration on behalf of the prospective Insured(s).
I have read and understood the Important Notices accompanying this Declaration.
I understand that, until a contract of insurance is entered into, I have a continuing obligation to promptly inform Allfin of any material change to the information contained in this Declaration. I acknowledge that, if a contract of insurance is entered into, this Declaration and any accompanying documents will form the basis of the contract.

I have read and agree to the above declarations. *

Signature *

Draw signature|Type signatureClear

Full name *

Position *

Date *

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