UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
PROPOSAL FORM FOR MEDICAL ESTABLISHMENTS
ERRORS & OMISSIONS INSURANCE

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.
Year in which established
3.
Names & address of owners / directors / partners
4.
Have you complied with all statutory rules/ regulations relating
to your establishment
5.
Are the Doctors / Nurses / Technicians working for you
a) Duly licensed in accordance with the Medical Acts or any
other prevalent laws
Members of Medical Association / Council?
6.
State the number of employees (including visiting doctors) in
each of the following classifications;
1. General Physicians
2. Plastic Surgeons
3. Dentists
4. Pharmacists
5. Technicians
6. Nurses
7. Trainees
8. Voluntary Workers
9. Other (Please specify)
10. Specialists including Surgeons in different disciplines.
a) Eye / ENT
b) Pathologists
c) Cardiologists
d) Radiologists
7.
a) Please specify all the facilities available like X-ray,
scanning, pathology, etc.
b) Whether persons operating these are qualified and well
experienced?
a)
b)
8.
Do you have ambulance?
If yes, specify number
9.
Do you have out patients department?
Please specify estimated No. of patient to be treated in a year.
10.
State
No. of beds maintained
No. of bassinets for maternity cases.
11.
Estimated No. of in-patients (actuals previous year; estimated current year)
to be treated in a year
PREVIOUS YEAR
(Actual)
CURRENT YEAR (Estimated)
a) General
b) Medical
c) Surgical
d) Any other class (Please specify)
12.
Give details of radioactive treatment facility, Specify
the materials used and precautions taken further for
such usage.
13.
Do you under take training of staff?
a) If yes, please give details
b) Nature of supervision over such trainees.
a)
b)
14.
Whether food is supplied by you to patients?
If yes, specify whether it is prepared by you or
supplied by outsiders.
If supplied by you, please specify the measures
taken for maintenance of kitchen and other
supervisory measures.
15.
Do you supply medicines to patients?
16.
State estimated annual income (this includes room
charges, Operation Theatre, Rent, charges for X-ray
facilities, doctors fees, nursing charges medicines,
food, surcharge and any other income)
17.
Details of the claim lodged against the proposer
during the past 5 years on account of services
rendered by your establishment
18.
Have you ever insured against liabilities in the past?
If so, specify the name of the insurer, policy number
and period.
19.
Has any insurer cancelled/declined/refused to renew
your liability insurance or accepted your proposal
subject to restrictions.
20.
Details of any event likely to give rise to a liability
claim against you at a future date
21.
State Limits of Indemnity required for: Any one year
22.
Period of Insurance Required
From
To
23.
Voluntary Excess if any
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 against the
company 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 : Signature of Proposer
Place :
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 respect 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/-.