Australian Hypnotherapists’ Association

Suite 3, 12-14 North Concourse, Beaumaris VIC 3193

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Australian Hypnotherapists’ Association

Thank you for visiting Focus Insurance Brokers. To obtain a quote, please complete and submit the information below.

Prior to completing this application, it is important that you read and understand your Duty of Disclosure obligations

After you submit this form, you will receive a quote and/or communication from us within 2 business days.

Insured Name

(Should include practitioner name (You) and business entity)

Australian Hypnotherapists’ Association Membership Number

ABN

Registered Business Address

(Please enter one address only. Your policy will provide Australia wide cover)

Email Contact

Phone Contact

Modalities you require cover for

(i.e. Hypnotherapy, Reiki, Hypnobirthing, Professional / clinical Supervision, etc)

Please confirm that you hold industry recognised qualifications for all Modalities you have nominated above

I agree

General Questions

Do you arrange, manage or provide workshops / seminars with over 20 participants at any given time?

Yes

Do you conduct, manage, arrange or provide retreats / accommodation / overnight stays?

Yes

Do you sell, supply, distribute, manufacture, licence any goods or products OTHER THAN books, magazines, written or online material relating to counselling?

Yes

Do any of the activities you undertake involve invasive procedures or piercing of the skin?

Yes

Do you require this policy to cover any other allied health professionals including employees or contractors other than you?

Yes

Do you require cover for overseas work and/or clients located overseas?

Yes

If you have answered Yes to any of the above questions, please provide details below

Claims and Circumstances

Has there been or is there now pending a claim against You or any other person / entity to be covered under this policy?

Yes

Have You or any other person / entity to be covered under this policy been the subject of any disciplinary proceeding or investigation?

Yes

Are You or any other person / entity to be covered under this policy aware of any facts or circumstances that might give rise to a claim now or in the future?

Yes

If you have answered Yes to any of the above claim questions, please provide details below

Other

Have you or anyone else to be covered by the policy been convicted of a criminal offence?

Yes

Have you or anyone else to be covered by this policy been declared bankrupt?

Yes

If you operate your business in NSW, are you a small business eligible for the exemption from the requirement to pay NSW duty on certain types of insurance? Generally speaking, you are a small business if your aggregated turnover is less than $2million. For more information visit www.revenue.nsw.gov.au/taxes/insurance/exemptions

Yes

I do not operate a business or provide services in NSW

Are there any facts or circumstances that You are aware of that may affect Our consideration of this proposal for insurance?

What is your preferred policy start date?

(We are not able to back-date your policy)

Declaration

I/We confirm that:

All answers / statements made are true, correct and complete

No information material to your application for this insurance has been withheld

I have read and understood my Duty of Disclosure obligations

I acknowledge that the Insurer relies on the information and representations made in relation to this insurance.

I understand that the information and answers you provide will be treated by the Insurer as information and statements made by all persons to be covered by the insurance.

I undertake to inform the insurer immediately of any material changes to this information after this form is submitted.

Signature field

Email address

How can we help you?

Hi David,
I have to congratulate you on making this such an awesomely easy process.
This is the way cloud technology should be used, a win-win for both parties.
Excellent! Love it!

Ed Henry

Director - Sage Australia Pty Ltd

Get in touch

03 8521 7180

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