IAN - Indian Academy of Neurology

PROFESSIONAL INDEMNITY POLICY FOR DOCTORS

Policy covers Legal Liability arising out of negligence on the part of Doctors whilst rendering their services
Doctors can opt for the yearly limit of Indemnity

PROFESSIONAL INDEMNITY PROPOSAL FORM FOR IAN MEMBERS/IAN MEMBER'S SPOUSE/CHILDREN

Choose Insurance Policy for

Life Membership No. *

First Name *

Middle Name

Last Name *

Mobile No. *

Phone No.

Email Id *

Correspondence Address

Street Address *

City *

State *

Pincode *

Clinic / Office Address: Same as Correspondence Address

Street Address *

City *

State *

Pincode *

Qualification & Year of passing

DM *

MBBS *

Speciality

Choose Insurance Policy Type *


Policy Cover	Annual Premium (inclusive 18% GST and Rs 200 Administrative Charges)
Rs. 50 Lacs
Rs. 1 Crore

Payment Details

Demand Draft RTGS: Transfer funds Debit/Credit Card/Net Banking

I hereby declare that the above information and answers are true to the best of my knowledge and the IAN Secretary is authorized to sign this policy on behalf of me.

I/we do hereby declare that the above statements and answers are true to the best of my knowledge and all Statutory Provisions are duly complied with, I agree that this proposal shall be the basis of the contract between me and The New India Assurance Co. Ltd.

*Date :**
*Place :**

Signature of the Proposer

Name of Medical Association(s) of which you are member :
*You are a :**	Neuro Physician Neuro Interventionist	Anesthetist / Plastic Surgeon Surgeon Pathologist / Radiologist / Microbiologist Physician
Other Specialisation:
Any pending Medico legal proceedings against you?	Yes No
Any likelihood of future Medico legal proceedings?	Yes No

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