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Healthcare professionals, lawyers, Auditors, accountants, etc.
PROFESSIONAL INDEMNITY
The asterisk(*), part is a requirement.
PROPOSER
*
First Name
Last Name
ADDRESS
*
Country
County
Town
Postal address
Postal / Zip Code
KRA PIN NUMBER
*
COVER START DATE
*
Β -
Month
Β -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
COVER END DATE
*
Β -
Month
Β -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
NEXT OF KIN
BUSINESS GENERAL DATA
ONLY FOR MALPRACTICE COVER.
1 Institution full name
2 Business address
3 Date of establishment
4.Is the proposer;
1. Approved by public authority?(name and date of Β approval)Β Β Β Β Β Β Β Β Β 2. A member of hospital association(name and date of acceptance)
5.Is the proposer maintained in whole or part by public or private fund or adomnent (please specify)
6.Medical assistants(pharmacists, laboratories, technicians etc)
7.Number of nurses(graduates and undergraduates or students)
8.Number of beds(including maternity cases)
9.Does the proposer own or operate x-ray, lasers, ultrasound machines or similar equipment's? if yes please specify number and usage.
10.Does the proposer use radioactive materials? If yes please specify machine and material used.
11.Does the proposer operate a blood bank? If yes please advice % of use for own purpose and for supply to other parties
PREVIOUS INSURANCE / PREVIOUS CLAIMS
Does the proposer previously insured?
If yes, please specify
*
Type a question
HAS A PREVIOUS APPLICATION BY A PREVIOUS INSURER?
Declined your proposal?
Required increased premium?
Required special restrictions?
Declined to renew your policy?
If yes to any of the above please specify
Proposer id copy
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proposer kra pin
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certificate of incorporation
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business kra pin
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DECLARATION
Signature
*
Date signed
*
Β -
Day
Β -
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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