Full Name: PIN NO:

Postal Address: Physical Location:

Main Mobile No: Alt Mobile No:

ID/Passport::

Are you politically exposed?

Profession

Area of Specialization

Which medical school did you obtain your basic medical training?

Graduation Year:

Which medical school did you obtain your post basic training:

Year of graduation:

Regulatory Authority registration number:

Are you a member of a professional Association?

Of what Professional Association are you a member?

Association Registration Number?

Name of Where you practice?

Where have you practiced your profession since graduation and what year(s)?
Practiced Profession: Years:
Practiced Profession: Years:
Practiced Profession: Years:
Practiced Profession: Years:

Limit of Liability Required

Are you at present or in the past insured for the proposed risks?

Has any proposal or renewal been?
Declined?
Withdrawn?
Charged an increased rate?
Required special restrictions?

Give particulars of all accidents or losses over the past three years:

Are there any impending claims or incidences that may give rise to claims against you for professional negligence?

If Yes, please provide details

The primary mode of delivery of policy document and other official documents shall be via email. Kindly provide your email address below:

Period of insurance From To