Cush Professional Indemnity quote form

PROFESSIONAL INDEMNITY

Gynaecologists,Obstetricians,All Surgeeons,Cardiologists,Opthalmologists,Urologists,Neurosurgeons,Orthopaedics, Dentist,General Practitioners,Family Medicine,Physicians,All others. Lawyers, engineers, surveyors, Auditors, valuers, Accountants, etc .
Please note;

The asterisk(✳️) part is required.
Full name *

First and middle NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Physical Address*

occupation

Location

CityTown

Postal / Zip Code
Kra pin*
Kenya revenue authority pin
School attended.*
Full name
Year of graduation *
Date inclusive
Specialization and years of experience *
E.g dentist -5 years experience
Are you duly registered by authorization body, if yes, state year of registration. Attach current retention certificate *
Are you a member of a union in profession*
If yes, state union membership number.
Where you have practised your profession since graduation.*
Where you have practised your profession since graduation.*
Please state when and where
Are you under contract with or in the employment of any individual, firm or corporate institution?*
If so ,give details
Are you in partnership or association with other professional(s)? *
If so, give details. (Each partner will fill in the proposal form individually)
Do you own, wholly or in part, operate or administer any other institution whereservices are customarily rendered?*
If so please give details
Do you own or operate X-ray Machines or Laser(Doctors)? *
If so please,give details
Gross income*
State the average number of people you attend to per year*
Have you or any of your partners suffered any loss resulting from professional negligence in the past five years? *
If so give details
Are there any impending claims or incidences that may give rise to claims against you for professional negligence? *
If so give details
Have you been insured of this risk before?*
If yes indicate name of the Insurance Company,
As any insurance Company EVER*
Total Indemnity Required*
Do you wish to cover past work?,(Extension is relevant if you have been having active Professional Indemnity Cover elsewhere on claims made basis. *
If Yes, state retroactive date (Max. 2 years back):
If available, does the firm require any of below extensions? (Max. 10% of Limit of Liability)*
Declaration

/We do hereby declare that the above answers and statements are true, and that I/We have not withheld or suppressed any material facts. I/We also agree that this proposal together with any other information supplied by me/us regarding this insurance proposal shall be the basis of the contract between me/us and the Insurance Company.Signing this proposal form does not bind the proposer or underwriter to complete this insurance.
Date*

DayMonthYear
Date
Signature*

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PROFESSIONAL INDEMNITY

Please note;

Declaration