The New India Assurance Company Limited
Registered & Head Office : New India Assurance,87,M.G. Road,Fort,Mumbai - 400 001

Doctors and Medical Practitioners

Medical Establishments

Proposal Form For Professional Indemnity
ACCOUNTANTS/SOLICITORS/LAWYERS/COUNSELS/FINANCIAL CONSULTANTS
________________________________________________________________

This proposal must be signed. All questions must be answered. The completion and signature of this proposal does not bind the proposer or Insurer to complete a contract of Insurance.
If there is insufficient space to answer questions, please use additional sheets and attach it to this form.The Company does not assume any liabilities until the Proposal has been accepted and premium paid.

1. Name & Address of Proposer __________________________________ ___________________________________________________________
_______________________________

2. When established ___________________________

3. Full details of work carried on ____________________________
(Please attach brochure, information booklet,
etc. if any & specimen copy of contracts entered into)

(a)Names in full of all Partners/Directors/Principals ______________

Qualifications in full _______________
Date qualified ______________

How long principal in this practice _______________

(b) Is coverage required in respect of past work for
any Partner/Principal who has left, retired or
died ? YES/NO. If ‘YES’ please give the following :

Full Name ___________________________
Qualifications ___________________________
How long principal in this practice _________________________
5. State :
(a) No. of qualified accountants/lawyers _____________
No. of Professionals ______________
No. of administrative personnel including clerks,
typists, office boys, etc. ______________
No. of apprentice ________________

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(b) Total amount of annual wages payable ____________

6. Do you engage persons outside your organisation ? If Yes,
specify the details of purpose and nature of control exercised
by you over them (specimen contract be enclosed).

7. Loss record for 5 years :

Year Cause Kind of Loss Amount of Loss

19
19
19
19
19

8. Have you during the past 12 months dismissed or do ___________
you contemplate dismissal of any member of staff an
account of any omission, neglect, error or for like
(please give full details)

9. Are you aware of any neglect, omission or error or
existence of any circumstances likely to give rise to
a claim ? ________________________________

10. (a) Annual fees earned during the last five years Year _______ Fee _____

(b) Estimated fees for the current year _____________________

11. Previous Insurance history ______________________

12. Limits of Indemnity required : Any One year ___________________

13. Voluntary Excess __________________

14. Period of Insurance required___________From_______________To

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I/We hereby declare that the above statement and particulars are true and I/we have not suppressed or misstated any material facts and that at the present time I/we have no reason to anticipate any claim being brought against me/us for any negligent act, error or omission on my/our part and agree that this declaration shall be the basis of the contract between me/us and the Insurer. I/we also agree that the indemnity under the insurance shall not be availed for claims arising out of acts of negligence, error or omission or misconduct committed PRIOR to commencement of this insurance.

Date : .....................
Place :......................
SIGNATURE OF PROPOSER

PROHIBITION OF REBATES
The following is the copy of Section 41 of the Insurance Act 1938.
1. 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 live or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown in the policy; nor shall any person taking out or renewing continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses of rebates of the Insurer.
2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.