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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