THE ORIENTAL INSURANCE COMPANY LTD. Proposal Form for Medical Establishment

Proposal Form for Medical Establishment

Errors & Omissions Insurance

(A Govt. of India Undertaking)

Name of Proposer

Address

Pincode

Phone Number

Year in which established

Gst Number

Names & Address of owner/directors/partners

Have You complied with all statutory rules/regulations, relating to your establishment?

Yes

Are the Doctors/Nurses/Technicians working for you:

Duly licensed in accordance with the medical acts or any other prevalent laws

Member of Medical Association/Council

State the number of employees (including visiting doctors):

Cont./Gen. Physician

Cardiologist

Neurologist

Pediatrician

Dermatologist

Gastroenterologist

Nephrologist

Psychiatrist

Radiologist

Pathologist

Nurses/Staff

Trainees

Plastic Surgeon

Anesthetist

General Surgeon

Orthopedic Surgeon

Obst. & Gynecologist

Eye Surgeon

ENT Surgeon

Neuro Surgeon

CTVS Surgeon

Dental Surgeon

Pharmacists

Technicians

Other Facilities

Please specify all the facilities available (e.g., X-ray, scanning, pathology):

Do you have Ambulance?

Do you have Out-patient departments?

Please specify estimated No. of out patients to be treated in a year

Previous year: estimated current Year to be treated in a year

Give details of radioactive treatment facility. Specify the material used and precautions taken further for such usage

Do you undertake training of staff
If yes, please give details

Nature of supervision over such trainees.

Nursing charges, Medicines, Food, Surcharges and any other income

Details of claims lodged against the proposer during the past 5 years on account of services rendered by your establishment

Have you ever insured against liabilities in the past ? if so, specify the name of the insurer, policy number and period

Has any insurer cancelled/ declined/ refused to renew your liability insurance or accepted your proposal subject to restrictions

Details of any event likely to give rise to a liability claim against you at a future date

State estimated annual income:

Details of claims lodged against the proposer during the past 5 years on account of services rendered by your establishment

State limits of indemnity requested of anyone year

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:

Do you supply medicines to patients

Date

Place

Upload PDF Document Include Hospital Registration Certificate, Aadhaar, PAN, and Photo in a single PDF

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Proposal Form for Medical Establishment

Errors & Omissions Insurance

About Company

Services

Medical Negligence

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Proposal Form for Medical Establishment

Errors & Omissions Insurance

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