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Application for Professional Indemnity, General and Statutory Liability insurance for members of the International Institute for Complementary Therapists
Please complete and return this proposal form to Aon New Zealand atThis Policy will cover your liability arising out of your business activities that are connected to the Modalities selected in this insurance application.
PRIVACY ACT 1993
As the Applicant or on behalf of the applicant, I authorise Aon New Zealand to disclose the information contained within this proposal application for insurance cover, to the insurers subscribing to the insurance policy as proposed. I understand that all information, which is collected, will be held at the office of Aon New Zealand, level 3, 1 Willis Street, Wellington and copies of this proposal will be held at the offices of both the insurers and Aon New Zealand. The Applicant is entitled to access this information, and if necessary to request the correction of this.
SECTION A: Individual Policy Holder
- Member Application Details
Mr Mrs Miss Ms Dr
Name: First name / Surname
Name of Legal Entity to be included / Note if you require cover for an incorporated practice please complete, in addition to Sections A & C, Section B of this proposal form
Postal Address:
Suburb
(Town/City) / Post Code:
Phone Number: / +64 / Mobile Number:
Email Address: / Web site
ModalitiesState the modalities that you are qualified to practice and wish to have cover under this insurance application.
Does your modality involve animals? / YES NO
If YES, What animals e.g. Canine, Equine (excluding thoroughbred race horses), Thoroughbred Race Horses, Bloodstock etc.
Qualifications Please state yourQualifications relevant to the Modalities declared :
Where did you obtained your qualifications (including name of college or training institute or training programme as applicable) / When Obtained
Please state your IICT level of Membership Full Executive Student
- Policy Coverage options - Please select the level of insurance required
- Professional Indemnity, General & Statutory Liability $1,000,000 in the annual aggregate
- Professional Indemnity, General & Statutory Liability $2,000,000 in the annual aggregate
- Modalities involving Animals- if you have answered yes, this premium is required in addition to the above options
SECTION B Optional Extension: Insurance cover of an Incorporated Practice
If you own a limited liability company and wish to include this entity in addition to your individual policy, please complete the below section. (the business must be in connection with the Modalities included in the individual policy)
Please provide gross fees or income / In your last Financial year $ / In the current financial year (actual and estimate) $
When was the business incorporated?
Has the business name changed or has any other business amalgamated or merged with you? / YES NO
If Yes please provide details
Numbers of Staff / Employees Full Time / Employees Part Time / Contractors Full Time / Contractors Part Time
Principals/Directors
Qualified Staff
Administrative/
Clerical
Other
1. Professional Indemnity, General & Statutory Liability $1,000,000 in the annual aggregate / $385.30
2. Professional Indemnity, General & Statutory Liability $2,000,000 in the annual aggregate / $529.00
SECTION C: Insurance Declaration
Claims /Circumstances
If you answer Yesto any of the questions below, please provide details, including the nature of the matter, costs incurred including any fines and settlements, and state if the matter is open or closed. NOTE: Claims / Circumstances may result in increased premium and/imposed coverage restrictions.
Have any claim, complaint or investigation been taken against you in the past 5 years? / YES NO
Are you aware of any circumstances, which may give rise to a claim, complaint or investigation being made against you? / YES NO
Have you ever been subject to disciplinary proceedings by a professional body or statutory body? / YES NO
In relation to this type of insurance, has any Insurer declined, cancelled or required an increased premium or imposed special terms? / YES NO
If you have answered YES any of the above, please provide details below or on a separate sheet.
InsuranceHistory
Do you currently hold professional/medical indemnity insurance (To maintain Retroactive cover, evidence of insurance is required.) / YES NO
Declaration
I hereby declare that the above statements and particulars are in all respects complete and true, that they are material and that I have not suppressed or misstated any material facts and I agree that this application form shall be the basis of the contract with underwriters and deemed part of the insurance coverage issued to me and that the insurance will not be in force until the application has been accepted by the underwriters or their representatives. I understand and accept that this policy will NOT indemnify me in respect of matters already known to me prior to the date cover is granted by insurers.
NAME / DATE
Date, within the next 30 days, you would like Insurance to commence / DATE
SIGNATURE / DATED
Professional Indemnity insurance for members of International Institute for Complementary Therapists
Why Professional Indemnity Insurance?
Changes to Accident Compensation, Mental Health and other legislation mean that today’s health professionals face increased risk in their everyday activities. These legislative and social changes have made it necessary for you to take responsibility for your own professional protection and financial security.
Instead of relying on insurance or indemnity agreements from employers or unions, you can have your own specially designed insurance plan.
This plan is portable, which means you can take it with you if you change employment. This is a significant advantage over the system where many health professionals rely on their employers for indemnity and may be left uninsured when they resign or retire.
The policy provides indemnity against claims made against you because of an actual or alleged act or error in the course of your professional business. The claim could be for compensation, or a review of your practice standards or it may come in the form of an investigation or inquiry from a statutory body of regulator.
THE COVER
This insurance provides cover to an individual health practitioner, and their incorporated practice where this option is selected:
Indemnity limit Options of $1,000,000 and $2,000,000 are available, in respect of each and every claim and for all claims in the aggregate (the policy year)
This section of the cover does not involve any excess, i.e. all claims are paid in full up to the amount of cover.
Cover includes costs awarded against you as well as legal and other defence costs, whether the case against you is successful or not.
LEGAL AND DISCIPLINARY DEFENCE COSTS
This section will cover legal costs and expenses incurred in the defence of any action or enquiry brought against you such as Medical Disciplinary Hearings, Committees of Enquiry, Courts Martial, ACC Enquiries, Privacy Complaints Tribunal, Coroners Courts and the like.
PUBLIC / GENERAL LIABILITY – Claims resulting from products or ownership/occupation of property connected to your business as a health practitioner.
STATUTORY LIABILITY – Fines or Penalties made against you by an authorised body that claims jurisdiction to investigate, sanction or discipline following a complaint or concern over your competency or conduct in connection with your performance as a health practitioner. (exclusion apply for reckless or deliberate conduct)
Retroactive date
The Retroactive date of the policy will be the date of the first year the policy is taken. Retroactive date refers to the period ofbusiness activity covered (excluding all known claims and circumstances) for example a retroactive date of 30 March 2017 will cover claims relating to your business activities from30 March 2017 going forward. The Retroactive date is the date your insurance first commences i.e. policy inception and will continue to be this date in future policy years. If you are already insured under a policy covering this type of risk, the retroactive date of this policy will be the same as the retroactive date already held. To qualify you will need to provide evidence of your current retroactive date.
Disclosureofrelevantfacts - Yourdutyofdisclosure
Before youenterintoacontractofgeneralinsurancewithaninsurer,youhaveadutytodisclosetothe insurereverymatterthatyouknow,orcouldreasonablybeexpectedtoknow,thatisrelevanttotheinsurer’sdecisionwhethertoaccepttheriskof theinsuranceand,ifso, onwhatterms.
Youhavethesame dutytodisclosethosematterstotheinsurerbeforeyourenew,extend,vary orreinstateacontractofinsurance. Yourdutyhoweverdoesnotrequiredisclosureofamatter:
•thatdiminishestherisktobeundertakenby theInsurer
•thatiscommonknowledge
•thatyourInsurerknowsor,
•astowhich compliancewithyourdutyiswaivedby theInsurer.
Non-disclosure
Ifyoufailtocomplywithyourdutyofdisclosure,theinsurermaybeentitledtoreduceitsliabilityunderthecontractinrespectofaclaimormay cancelthecontract.
Ifyournon-disclosure isfraudulent,theinsurermayalsohavetheoptionofavoidingthecontractfromitsbeginning.
Therequirementoffullandfrankdisclosureofanythingwhich maybematerialtotheriskforwhich youseekcover(e.g.claims,whetherfounded orunfounded), ortothemagnitudeoftherisk,isoftheutmostimportancewiththistypeofinsurance.Itisbettertoerronthesideofcautionby disclosinganythingwhich mightconceivablyinfluencetheinsurer’sconsiderationofyourproposal.
Claimsmadeandnotifiedpolicy
This proposalisfora“claimsmadeandnotified”policy ofinsurance.Thismeans thatthepolicy coversyouforclaimsmadeagainstyouandnotified totheInsurerduringtheperiodofcover.
This policy doesnotprovidecoverinrelationto:
•eventsthatoccurredpriortotheretroactivedateofthepolicy (ifsuchadateisspecified);
•claimsmadeaftertheexpiryoftheperiodofcovereven thoughtheeventgivingrisetotheclaimmayhaveoccurredduringtheperiodofcover;
•claimsnotifiedorarising outoffactsorcircumstancesnotified(orwhich oughtreasonablytohavebeennotified)underanypreviouspolicy;
•claimsmade,threatenedorintimatedagainstyoupriortothecommencementoftheperiodofcover;
•factsorcircumstanceswhich youfirstbecameawareofpriortotheperiodofcover,andwhich youkneworoughtreasonablytohaveknownhad thepotentialtogiverisetoaclaimunderthispolicy;
•claimsarisingoutofcircumstancesnotedontheproposalformforthecurrentperiodofcoveroronanypreviousproposalform.
However,whereyougivenoticeinwritingtotheinsurerofanyfactsthatmightgiverisetoaclaimagainstyouassoonasreasonably practicable afteryoubecomeawareofthosefactsbutbeforetheexpiryoftheperiodofcover,thepolicy will,subjecttotheterms andconditions,coveryou notwithstandingthataclaimisonlymadeaftertheexpiryoftheperiodofcover.
Uponexpiryofthepolicy nofurtherclaimscanbemadethereunderandtheneedtomaintaininsuranceorarrangement ofrun-offcoverisessential. Youshouldfamiliariseyourselfwithourstandardformofpolicy forthistypeofcoverbeforesubmitting thisproposal.
Utmost good faith
The duty of Utmost Good Faith is implied in every contract of insurance that you enter into. The duty requires you, the insurer, the broker and any other parties to the insurance contract to act openly and honestly with each other at all times. A breach of the duty of Utmost Good Faith could lead to a policy or a claim being voided by the insurer.
Non-transferable insurance / Individuals as Insureds
This insurance policy provides indemnity to individual persons as health professionals. It does not include incorporated entities and is not transferrable.
Territorial Limits
This insurance policy apply to the insured modality undertaken within the territorial limits of New Zealand only.
How do I make a claim?
It is important that you immediate inform insurers of a claim or you believe a claim may be made against you. Aon provide you with claims assistance and work with you to ensure your insurers manage your claim appropriately. For claims response call: Aon New Zealand, Ph +64 4 819 4000 and request the Professional Risks Claims Division.
What constitutes a claim or circumstance
If you become aware of a claim or of circumstances that could give rise to a claim in the future, you should notify us in writing immediately, so that we can notify your insurer on your behalf. If you become aware of a claim or of ‘circumstances’ and your insurer is not notified during the policy period, you could be left uninsured or facing a reduced payout from your insurer in respect of that claim or any future related claim.
A circumstance is one which when objectively evaluated, creates the reasonable and appreciable possibility that it will give rise to a loss, claim, complaint or investigation against you. The notification must be sufficiently specific that you can and do provide details of the names of the potential claimants and potential acts or omissions. If there is any doubt, notify.
Who is the Insurer?
Vero Liability Insurance is a specialist liability Insurer and underwriter of medical malpractice Insurance. In accordance with the Insurance (Prudential Supervision) Act 2010, Insurers receive a financial strength rating issued by Standard & Poors as follows:
A+ (good), issued by Standard & Poor's.
Rating Scale
AAA (Extremely Strong) / BBB (Good) / CCC (Very Weak)AA (Very Strong) / BB (Marginal) / CC (Extremely Weak)
A (Strong) / B (Weak) / R (Regulatory Action)
The ratings from ‘AA’ to ‘CCC’ may be modified by the addition of a plus (+) or minus (-) sign to show relative standing within the major rating categories. The rating scale above is in summary form. A full description of this rating scale can be obtained from
Who should I talk to?
Aon New Zealand are the appointed insurance broker to the IICT members insurance facility (New Zealand members only). Please return your completed proposal form; or for any queries, please contact:
Aon New Zealand | PO Box 2517 Wellington 6140
P 04 819 4135| E
Aon Remuneration
Aon receive commission payments from the insurer upon placement of an insurance policy. In addition to this Aon charge you an administration fee and will pay a portion of this to IICT as a referral agency of Aon. The Premium we quote you is inclusive of commissions and administration fees and Goods and Services tax.
AON TERMS OF BUSINESS
Except as may otherwise been agreed (in writing), you agree that Aon's Terms of Business apply to the provision of services by us. These terms are available at These terms have recently been amended and apply to all new business and renewals with effect from 1 June 2016.
Some key terms include:
Our obligation to perform our service competently, with reasonable care, skill and integrity;
Your obligation to supply us with all material information and facts in relation to the provision of our services. Relevant information includes all information and facts that may be material to an insurers' assessment of a risk for which you have asked us to arrange insurance cover;
Our disclosure of remuneration. Aon may receive consideration from insurers, banks and/or finance companies with whom they place insurance and associated services, on your behalf. Minimum service and administration fees may apply;
Limitation of liability. Among other things, to the extent permitted by law, our aggregate liability in respect of any claim howsoever arising is limited to NZ$1 million or such other amount as may be expressly agreed between us in writing. To the extent permitted by law, we are also not to be liable for any consequential, incidental, indirect or special damage or loss of any kind;
Our obligation to hold your personal information in accordance with the Privacy Act 1993. It will be necessary for us to pass your information on to insurers and other product or service providers which may provide us with additional support in connection with our provision of our services. Unless you instruct us not to do so, we may also contact you in connection with other products or services we feel may be of interest or benefit to you. You have rights of access to and correction of this information subject to the provisions of the Privacy Act 1993.
Making a Complaint
Please contact your Aon client relationship manager or your local Aon office by telephone, email or in writing if you have any complaint in respect to Aon. If your Aon client relationship manager is not able to resolve your complaint, it will be referred to Aon's complaint manager for an independent review in accordance with Aon's internal complaint and dispute resolution procedures. Alternatively, you can contact Aon's complaint manager directly on 09 362 9000 or you can email details of your complaint to us in writing at
If your complaint remains unresolved, or if you are dissatisfied with Aon's response to your complaint, you may refer the matter to Financial Services Complaints Limited by emailing or calling 0800 347257.