Medical Indemnity Insurance

Doctor's Professional Indemnity

Doctor's Name:

Mobile / Contact No.:

Residential Address:

Address of the Clinic *

Qualification & Year of Passing *

Branch of Medicine *

Registration No. *

Year of Registration *

Duration of Practice *

Membership No. *

Name of Medical Association or Council

Line of Profession: *

Line of Specialisation:

Are you attached to any hospital

Are you serving any organisation?

Limit of Indemnity (Cover) Required ? *

Average No. of Patients per day*

Any Pending Legal Proceedings against you? *

Any Likelihood of future legal proceedings? *

Details of Previous Year Insurance: (If Any)