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  Professional Liability Insurance Proposal Form - malpractice-for-hospitals

I- General Date
1- Full Name of insitution (hereinafter referred to as "the proposer") *
Mobile *
E-mail *
2- Business address *
3- Date of establishment *
4- Is the proposer
a- Approved by a policy authority ? Name of the authority and date of approval
 Yes     No
b- A member of a hospital association ? Name of the association and date of acceptance
 Yes     No
5- Is the proposer maintained in whole or in part by public or private funds or endowment ?
 Yes     No
Please specify
II- Nature and volume of your present and foreseeable future activities
1- Brief description of the proposer's activities (e.g. operations of a hospital, nursing home, sanatorium)
2- Estimated gross annual income (please indicate currency)
3- Number of patients per year
a- In-patients
b- Out-patients
4- Approximate division of patients between
a- General (%)
b- Surgical (%)
c- Gynaecological and obstetrical (%)
d- Paediatric (%)
e- Orthopaedic (%)
f- Dental (%)
g- Psychiatric (%)
h- Any others classes (%)
5- Number of employed doctors (including doctors in clinics) in each of the following classifications
a- Surgeons
b- Cosmetic surgeons
c- Anaesthetists
d- Gynaecologists
e- Internal specialists
f- Urologists
g- Orthopaedists
h- Radiologists
i- Ophthalmologists
j- Dentists
k- Physicians
l- Interns (licensed and unclicensed)
m- Others (please specify)
6- Number of medical assistants (Pharmacists, Laboratory technicians, etc)
7- Number of nurses
a- Graduates
b- Undergraduates or students
8- Number of beds (including for maternity cases)
9- Does the proposer own or operate X-ray machines, lasers, ultrasound machines or similar equipment ?
 Yes     No
If so, please specify and give number of machines, type and whether they are used for diagnosis or treatment or both.
10- Does the proposer use radioactive materials ?
 Yes     No
If so, please specify machinery and / or materials used.
11- Does the proposer operate a blood bank ?
 Yes     No
If so, please advise percentage of use
a- For own purpose (%)
For supply to other parties (%)
Previous Insurance / Previous Claims
1- Has the proposer previously been insured ?
 Yes     No
If so, please specify
Name of insurer Policy period Limit of indemnity
1-
2-
3-
4-
5-
2- Has a previous application been declined ?
 Yes     No
Has a previous insurance
a- Required increased premium ?
 Yes     No
b- Required special restrictions ?
 Yes     No
c- been terminated / not been renewed by an insurer?
 Yes     No
If so, please give detailed information
3- Have any claims or suits for malpractice been made during the past five years against the proposer?
 Yes     No
If so, please advise amount and background of each claim
4- Is the proposer aware of any circumstances or incidents which may result in a claim or claims against him
 Yes     No
If so, please give details
Indemnity required
1- Limit any one claim
2- Limit in the annual aggregate
3- Deductible each and every claim to be borne by insured
We declare that the statement and particulars in this proposal are true and that I/we have not misstated or suppressed any material facts. I/we agree that this proposal, to gether with other information supplied by me/us, shall form the basis of any contract of insurance effected thereon.
Signing this proposal form does not bind the proposer or underwriter to complete this insurance .
Date this               day of                 19

For and on behalf of _________________________________________(Insert name of proposer)

Signature of partner or principal ____________________________________
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