UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO: 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR DOCTORS’ AND MEDICAL PRACTITIONERS’
PROFESSIONAL INDEMNITY

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 liability until the Proposal has been accepted and premium paid.
1. Name of Proposer
2. a) Residential Address
b) Clinic Address
3. a) Professional qualifications and the year of such
qualifications
b) In which branch of medicine viz., Allopathy /
Homeopathy / Ayurvedic / Any other-please specify
4. a) Medical Registration No.
b) Year of Registration
c) How long have you been practicing
5. Are you a member of any Medical Association / Council?
If so, please State Name and Address of such Association /
Council with Membership No.
6. Are you a
a) General Practitioner /General Physician / Surgeon
b) Pathologist / Radiologist
c) Consulting Physician
d) Anesthetist / Plastic Surgeon
Note: If Specialist, please specify your line of
specialization.
7. a) Specify facilities such as dispensing facility, X-ray,
radiation therapy, scanning, ECG, Sonography, MRI,
etc., available / operated by you or under your control.
b) Are these facilities being maintained through regular
service contracts with the manufacturers/ specialized
servicing Agencies?
c) If these facilities are operated by employees please
state their i) names ii) technical qualification iii)
experience and iv) name of the facility operated
(please use separate sheet)
d) Please indicate whether you wish to extend the policy
to cover, out of the above list, personal who are not
qualified to operate the facility mentioned against their
names
8. Specify No. of employees, their job specifications their
experience and nature of your supervision.
9. a) i) Are you attached to /or attending as a visiting
physician / surgeon in any Hospital / Nursing Home /
Clinic etc.,
If yes, please give details:
ii) Are you in service with any organisation?
If yes, then please give name & address of the same.
b) Are they covered under a Medical Establishment-
Errors & Omissions policy?
1
0.
State the average number of patients you are attending per
day
11
.
Have any claims been made upon you or legal
proceedings instituted or likely to be instituted
against you by patients in respect of your treatment
etc., If so, please give details.
1
2.
Have you been previously insured for the subject
risk? If so, give full particulars
1
3.
Has any Company
a) declined your proposal
b) required an increased premium
c) refused to renew your policy
d) cancelled such a policy
1
4.
Limit of Indemnity required
Any one Accident Rs.
Any one year Rs.
1
5.
Period of Insurance
From
To
I / We do hereby declare that the above statements and answers are true and what I / We have not with
held any information whatsoever regarding the proposal. I / We hereby declare that all statutory
provisions relating to my/our business proposed for insurance are complied with. I / We agree that this
proposal and declarations shall be the basis of the contract between me/us and
------------------------------------ whose policy for the insurance proposed is acceptable to me/us. I / We
under take to exercise all ordinary and reasonable precautions for safety of the property as if it were
uninsured.
Date :
Place :
Signature of Proposer
Development Officer’s Report:
The Proposer is known to me/my Agent for ------------------------------- years and recommend
acceptance of this proposal.
Date :
Place :
Signature of Development Officer
Name and Code No. of Development Officer
Note: 1) The liability of the Company does not commence until the proposal has been accepted by the
Company and premium paid.
2) Premium will be quoted on application.
SECTION 41 OF THE INSURANCE ACT 1938
PROHIBITION OF REBATES
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 receipt of any kind or risk relating to lives or
property in India any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy nor shall any person taking out or continuing a policy accept any
rebate except such rebate as may be allowed in accordance with the prospectus or tables 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 Rs.500/-.