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.

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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

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(14)Details of Previous Insurance IF any?
(15)Limit of Indemnity Required(Sum Insured)
(16)Period Of Insurance
From
TO
email*
Signature of Proposer

Clear
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: