HOSPITAL INDEMNITY INSURANCE

1. NAME OF PROPOSER*
2. YEAR OF ESTABLISHMENT & REGISTRATION NUMBER*
3. HOSPITAL NAME & ADDRESS*
4. NAME & ADDRESS OF OWNERS/DIRECTORS/PARTENERS (Mobile No.)
5. (a) DULY LICENSED IN ACCORDANCE WITH MEDICAL ACTS OR ANY OTHER PREVALENT LAWS
5. (b) MEMBER OF MEDICAL ASSOCIATION / COUNCIL
6. STATE THE NUMBER OF EMPLOYEES *
7.(A) STATE THE NUMBER OF VISITING DOCTORS
7. (B) STATE THE NUMBER OF DOCTORS (PERMANENT)
8. (a) PLEASE SPECIFY ALL THE FACILITIES AVAILABLE LIKE X-RAY, SCANNING, PATHOLOGY etc.*
8. (b) DO YOU HAVE AMBULANCE? IF YES SPECIFY NUMBERS
9. DO YOU HAVE OUTPATIENT DEPARTMENT ? PLEASE SPECIFY ESTIMATED NUMBER OF PATIENTS TO BE TREATED IN A YEAR.*
10. STATE NUMBER OF BEDS MAINTAINED*

1O. (A) NO. OF BASSINETS FOR MATERNITY CASES
11. (A) ESTIMATE NO. OF IN-PATIENTS previous year (actual)
11. (B) ESTIMATE NO. OF OUT-PATIENTS (actual) *
12. DO YOU SUPPLY MEDICINES TO PATIENTS (YES/NO)*
13. DETAILS OF ANY CLAIMS LODGED AGAINST THE PROPOSER DURING THE PAST FIVE YEARS ON ACCOUNT OF SERVICES RENDERED BY YOUR ESTABLISHMENT.
14. YOU EVER INSURED AGAINST LIABILITIES IN THE PAST ? IF SO PLEASE SPECIFY THE NAME OF THE INSURER,POLICY NO. & PERIOD
15. HAS ANY INSURER CANCELLED/DECLINED/REFUSED TO RENEW YOUR LIABILITY INSURANCE OR ACCEPTED YOUR PROPOSAL WITH RESTRICTIONS. (YES / NO)*
16. DETAILS OF ANY EVENT LIKELY TO GIVE RISE TO A LIABILITY AGAINST YOU AT A FUTURE DATE
17. STATE LIMIT OF INDEMNITY REQUIRED FOR ONE YEAR (SUM INSURED)*
18. PERIOD OF INSURANCE FROM :
TO
Signature
DateTime
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. 10,000 (example)
Add sender name :YOUR NAME ex. Vijay Hospital
Certificate of registration of hospital with the municipal authorities (copy)

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