Professional Indemnity Proposal Form

Name

PrefixFirst NameMiddle NameLast Name
PAN & AADHAR NO

PancardAadharcard
Date of Birth
Mobile No..
Res. Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Hospital / Clinic Address

Street Address

Street Address Line 2

Street Address Line 3City, State / Province

Postal / Zip Code
1)Qualification & Year.
2)Branch Of Medicine
3)Registration No.
- 4)Year of Registration.
- 5)Duration of Practice
- 6)Membership No.
- 7)Name of Medical Association or council
- (8)Are you a (1)General Practitioner/ General Physician (2)Pathologist/Radiologistc) (3)Consulting Physician (4)Anaesthetist/Plastic Surgeon (5)Other Specialisation
- (9) Are you attached to any Hospital or NursingHome etc. If yes give details
- (10)Are you serving in any organisation? If yes,Please specify
- (11)Average Number of Patients attended per day.
- (12)Any pending Legal Proceedings against you
- (13)Any likelihood of future legal proceedings
- (14)Details of Previous Insurance IF any?
- (15)Limit of Indemnity Required(Sum Insured)
- (16)Period Of Insurance
- From
- TO
- email
- Signature of Proposer
- Pay Premium by NEFT/IMPS and forward transation ID
  CENTRALIZED /NEFT PREMIUM COLLECTION ACCOUNT DETAILS.
  Benificiary Name : United India Insurance Company Ltd.
  Bank Name : Indusind Bank
  Bank branch : Nungambakkam, Chennai
  Current AC No. 200999095210180300
  IFSC CODE : INDB0000007
  Amount. 10000 (example)
  Add sender name :YOUR NAME ex. Vijay Prasad
- Should be Empty: