Completing this online Proposal Form

Please answer all questions giving full and complete answers.
It is the duty of the proposer to provide all information that is requested in this Proposal Form as well as to disclose relevant facts. A relevant fact is a known fact or circumstances that may influence the evaluation of risk by the insurer. If you are uncertain about what a relevant fact is, please contact us.
If renewing an existing policy with Fenton Green, please ensure you check all information and make any necessary changes.

The Practice Cover Mini Policy provides $500,000 cover any one claim and, in the aggregate, (costs inclusive).

Insured Details

First Name:

Last Name:

Your Email address

Re-enter Email address

Your Contact Phone Number

Address Details

Street Number/ Name:

Suburb:

State:

Postcode:

Period of Insurance

Policy Start Date

Yes

I hereby declare that I am a small business entity (within the meaning of section 152-10 (1AA) of the Income Tax Assessment Act 1997 of the Commonwealth). I am a small business individual/partnership/company and/or trust, which is carrying on a business, and the business has an aggregated turnover of less than AUD $2 million.