Info Doctcare Services : India's Largest Professional Risk Management Service Provider for Doctors, Hospitals,Nursing Homes & Diagnostic Centers

THE ORIENTAL INSURANCE COMPANY LTD.

(A Govt. of India Undertaking)

This Proposal must be signed. All questions must be answered. The completion and signature of this proposal does not imply a contract of insurance.

1. Name of the Proposer

2. Father/Spouse Name

3. Marriage Anniversary

Date Of Birth

4. Email

5. Mobile No

6. Address

7. Pincode

8. Professional qualification and the year of such qualification

9. Medical Registration No. & Year

10. Are you a member of any Medical Association/Council?

11. State the address of your Clinic/Chamber

12. Are you attached to any hospital? If yes, please give details

13. Are you a general physician, surgeon, dentist, specialist, or consultant physician?

14. How long have you been practicing?

15. Estimated Annual Income

16. Specify facilities such as X-ray, radiation therapy, scanning etc. operated by you

17. Average number of patients you attend per day

18. Limit of Indemnity (Any one Act, Any one Year)

19. Extension for unqualified staff

20. Have any claims been made against you or legal proceedings instituted?

21. Have you been previously insured for the subject risk? Provide details.

22. Has any company ever declined or refused to renew your policy?

23. Period of insurance

Declaration

I hereby declare that the above statement and particulars are true and I have not suppressed or misstated any material information.

Date

Place

Upload PDF Documents Aadhaar, PAN, and Medical registration certificate in a single PDF