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    DoctorPI Proposal Form UIIC

    Uploaded by

    fardoctor
    It requests information such as the applicant's name, address, professional qualifications, medical registration details, medical association memberships, medical specialization, average daily patient load, hospital affiliations, details of any prior professional indemnity policies, and any past or potential malpractice claims. It also requests the desired liability limit and policy period. The applicant declares that all information provided is true and agrees to the terms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    DoctorPI Proposal Form UIIC

    Uploaded by

    fardoctor
    32 views2 pages
    It requests information such as the applicant's name, address, professional qualifications, medical registration details, medical association memberships, medical specialization, average daily patient load, hospital affiliations, details of any prior professional indemnity policies, and any past or potential malpractice claims. It also requests the desired liability limit and policy period. The applicant declares that all information provided is true and agrees to the terms.

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    It requests information such as the applicant's name, address, professional qualifications, medical registration details, medical association memberships, medical specialization, average daily patient load, hospital affiliations, details of any prior professional indemnity policies, and any past or potential malpractice claims. It also requests the desired liability limit and policy period. The applicant declares that all information provided is true and agrees to the terms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views2 pages

    DoctorPI Proposal Form UIIC

    Uploaded by

    fardoctor
    It requests information such as the applicant's name, address, professional qualifications, medical registration details, medical association memberships, medical specialization, average daily patient load, hospital affiliations, details of any prior professional indemnity policies, and any past or potential malpractice claims. It also requests the desired liability limit and policy period. The applicant declares that all information provided is true and agrees to the terms.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    UNITED INDIA INSURANCE COMPANY LIMITED

    REGD & HEAD OFFICE : 24, WHITES ROAD, CHENNAI - 600014


    PROPOSAL FORM FOR DOCTORS’ AND MEDICAL PRACTITIONERS PROFESSIONAL INDEMNITY
    1. Name of Proposer

    Mobil No.

    Email Id.
    2. Residential Address

    3. A) Professional Qualification and year of such qualification


    B) In which brand of medicine viz. Allopathy, Homeopathy,
    Ayurveda or any other?
    4. A) Medical Registration Number
    B) Year of Registration
    C) How long have you been practicing?
    5. Are you a member of any Medical Association ?
    If yes, please state name of such Association & membership no.
    6. A) Are you’re a General Physician, MBBS, General
    practitioner, Family Physician, radiologist, Pathologist or
    MD, Plastics Surgeon, Anaesthetist, Surgeon?

    B) If any, please specify your line of specialization.


    7. State the average number of patients you are attending per day?

    8. Are you attached to/or attending as a


    visiting physician/surgeon in
    any Hospital/Nursing Home/Clinic etc.
    If yes please give details.
    9. Does the proposer currently hold any Professional Indemnity
    Insurance?
    If yes, please give
    details:
    enewal date
    imit of Indemnity
    etro-active date
    10. Have any claims been made upon you or legal proceeding
    instituted or likely to be instituted against you by patients in
    respect of your treatment etc.? If so, please give details.
    11. Limit of indemnity required
    A) Any One Accident (AOA)
    B) Any One Year (AOY)
    12. Period of Insurance
    From / / To / /

    I / We do hereby declare that the above statements and answers are true and what I / We have not withheld any information whatsoever regarding the proposal. I / We hereby declare that
    all statutory provisions relating to my/our business proposed for insurance are complied with. I / We agree that this proposal and declarations shall be the basis of the contract between
    me/us and United India Insurance Whose policy for the insurance proposed is acceptable to me/us. I / We undertake to exercise all ordinary and reasonable precautions for safety of the
    property as if it were uninsured.

    Date:
    Place: Signature of Proposer

    Declaration

    I/we hereby authorize SecureNow to act our exclusive insurance broker for placing our Professional Indemnity Policy.

    Date:
    Place: Signature of Proposer
    Note: 1. The liability of the Insurance Company does not commence until the proposal has been accepted by the Company and premium credited in their account
    2. Premium will be quoted on application.

    SECTION 41 OF THE INSURANCE ACT


    1938 PROHIBITION OF REBATES

    No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in receipt of any
    kind or risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium shown on the
    policy nor shall any person taking out or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus
    or tables of the Insurer.

    Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend to Rs.500/-.

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