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  Professional Indemnity Insurance Proposal Form Medical Malpractice for practitioners

These proposal forms are not a proof of cover unless a written confirmation is given by our company.


I- General data
1- Full Name *
Mobile *
E-mail *
2- Business address *
3-a- At what medical school did the proposer graduate ? *
b- Year of graduation *
4- Where has the proposer practiced his profession since graduation ?
In From To
5- Is the prposer duly licensed in accordance with law to practice at the address given under item 2?
 Yes     No
6- Member of association ?
 Yes     No
II- Nature and volume of your present and foreseeable future activities
1- Is the proposer or assistant practising as
a- Physician
 Yes     No
b- Surgeon
 Yes     No
c- Cosmetic surgeon
 Yes     No
d- Anaesthesist
 Yes     No
e- Gynaecologist
 Yes     No
f- Urologist
 Yes     No
g- Orthopaedist
 Yes     No
h- Radiologist
 Yes     No
i- Dentist
 Yes     No
j- Any other not shown
 Yes     No
If so, please specify.
2- Is the proposer, partner or assistant regularly involved in first-aid service ?
 Yes     No
3- Name(s) of partner(s) for each partner all questions listed above have to be answered individually
4- Name(s) of qualified medical assistant(s)
5- Number of technicians employed
6- Number of nurses employed
7- Is the proposer under contract with or in employ of any individual firm or cooperation ?
 Yes     No
If so, please give details
8- Does the proposer own, wholly or in part, operate or administer any hospital nursing home or other institution where medical services are customarily rendered ?
 Yes     No
Does he have any reserved beds there ?
 Yes     No
If so, please give details including number of reserved beds.
9- Does the proposer own or operate X-ray machines or laser ?
 Yes     No
If so, please give number type and whether they are used for diagnosis or treatment or both.
10- Number of patients per year
III- 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 against the proposer or any of his partners, assistants, nurses or technicians during the past five years ?
 Yes     No
If so, please advise amount and background of each claim
4- Is the proposer or any of his partners, assistants, nurses or technicians aware of any circumstances or incidents which may result in a claim or claims
 Yes     No
If so, please give details
IV- Indemnity required
1- Limit any one claim
2- Limit in the annual aggregate
3- Deductible each and every claim to be borne by insured
I/We declare that the statements 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, together 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                 20

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

Signature of partner or principal ____________________________________
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