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Professional Indemnity Doctors

This document is a proposal form for doctors seeking professional indemnity insurance. It requests information such as the doctor's name, address, qualifications, years of experience, medical facilities available, number of patients seen per day, past insurance history, and the limits of indemnity required. The form must be signed by the proposer. It notes that completion of the form does not bind the insurer to provide a policy. It also contains standard legal notices about prohibiting rebates under insurance law.

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43 views3 pages

Professional Indemnity Doctors

This document is a proposal form for doctors seeking professional indemnity insurance. It requests information such as the doctor's name, address, qualifications, years of experience, medical facilities available, number of patients seen per day, past insurance history, and the limits of indemnity required. The form must be signed by the proposer. It notes that completion of the form does not bind the insurer to provide a policy. It also contains standard legal notices about prohibiting rebates under insurance law.

Uploaded by

kandulasbooks
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PROPOSAL FORM FOR DOCTORS’ AND MEDICAL

PRACTITIONERS’
PROFESSIONAL INDEMNITY
Completion and signature of this proposal does not bind the proposer or Insurer to complete a contract of Insurance.

1) Name of Proposer ______________________________________________________________________


2) This proposal must be signed. All questions must be answered. The
a) Residential address ________________________________________________________________
________________________________________________________________________________
b) Clinic address ____________________________________________________________________
________________________________________________________________________________
3) a) Professional Qualifications and the year of such qualifications _____________________________
________________________________________________________________________________
b) In which branch of medicine viz. Allopathy/Homeopathy/Ayurvedic/Any other - please specify
________________________________________________________________________________
4) a) Medical Registration No. ___________________________________________________________
b) Year of Registration _______________________________________________________________
c) How long have you been practicing ___________________________________________________
5) Are you a member of any Medical Association/Council? If so, please state Name and Address of such
Association/Council with Membership No.___________________________________________________
_____________________________________________________________________________________
6) Are you a -
a) General Practitioner/General Physician _______________________________________________
b) Pathologist/Radiologist ____________________________________________________________
c) Consulting Physician ______________________________________________________________
d) Anaesthesist/Plastic Surgeon _______________________________________________________
Note:
If Specialist, please specify your line of specialisation.
7) a) Specify facilities such as dispensing facility, X-ray radiation therapy, scanning ECG, Sonography,
MRI, etc.available/operated by you or under your control. _________________________________
———————————————————————————————————————————
b) Are these facilities being maintained through regular service contracts with the manufacturers/
specialised servicing Agencies ? ————————————————————————————
———————————————————————————————————————————
c) If these facilities are operated by employees please state their i) names ii) technical qualification
iii) experience and iv) name of the facility operated (please use separate sheet)

176
d) Please indicate whether you wish to extend the policy to cover, out of the above list, personnel who
are not qualified to operate the facility mentioned against their names.
8) Specify No. of employees, their job specifications, their experience and nature of your supervision.
9) a) i) Are you attached to/or attending as a visiting physician/surgeon in any Hospital/Nursing
Home/Clinic etc. If yes, please give details: _______________________________________
___________________________________________________________________________
ii) Are you in service with any organisation ? If yes, then please give name & address of the
same.
___________________________________________________________________________
b) Are they covered under a Medical Establishment- Errors & Omissions policy? ________________
________________________________________________________________________________
10) State the average number of patients you are attending per day. _________________________________
11) Have any claims been made upon you or legal proceedings instituted or likely to be instituted against you
by patients in respect of your treatment etc. If so, please give details. _____________________________
______________________________________________________________________________________
12) Have you been previously insured for the subject risk? If so, give full particulars. ____________________
______________________________________________________________________________________
13) Has any Company
(a) declined your proposal ________________________________________________________________
(b) required an increased premium __________________________________________________________
(c) refused to renew your policy ___________________________________________________________
(d) cancelled such a policy ________________________________________________________________
14) Limit of Indemnity required For
Any One Act - Rs. ________________________________________________________________________
Any One Year Limit - Rs._________________________________________________________________

15) 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 The New India Assurance Co. Ltd.
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

177
NOTE
1. The liability of the company does not commence until the proposal has been accepted by the Company
and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Premium will be quoted on application.
4. Insurance is the subject matter of solicitation.
PROHIBITION OF REBATE — Section 41 of the Insurance Act 1938
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 respect of any kind of risk relating to lives or property in India, any
rebate of the whole part of the commission payable or any rebate of the premium shown on the policy nor
shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as
may be allowed in accordance with the published prospectuses 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 Five Hundred Rupees.

FOR OFFICE USE


MARKETING / DEVELOPMENT OFFICER’S REPORT

The Proposer is known to me/my agent / Broker for____________ years and I recommend acceptance of
this proposal.
Name and Code No. Signature of Dev. Officer / A/AO-D
ACCEPTED BY _______________________________ DATE & TIME ________________________________

RATE _______________________________________ REMARKS __________________________________

CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-COLLECTION /

SCROLL NO _______________________________ POLICY NO. _________________________________

178

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