Registration form

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INDIAN MEDICO LEGAL
IMS
S E R V I C E S
Head Off: 204, S.F., Parmesh Business Centre, DDA Commercial Complex,
Karkardooma, (Nr. K.K.D. Metro Station) Delhi-92.
Contact No. : +91-9897730260, +91-9990353185
Email: [email protected]
visit us at www.imsprotection.com
INDIAN MEDICO LEGAL
S E R V I C E S
REGISTRATION FORM
DATE
MONTH
Branch.............................
ID. No. .............................
YEAR
As per the Services of Indian Medico Legal Services. I hereby voluntarily declare to be member of IMS for which deposit a
sum Rs. ................................................................. for .............................................year/years and I am quoting my details below.
I understand that the expenses to be incurred on professional Indemnity Insurance policy and Medico Legal Services
charges shall be met with above deposit.
Amount
D/D or Payee Cheque No.
Date
Drawn on
Notes
PARTICULARS
Full Name
Dr.
Husband's/Father's Name
Qualification Detail/Details
Clinic/Hospital/Nursing Home
Residential Address
Clinic
Residence
Telephone
Date of Birth
Medical Registration No.
Year
Email Id :
I Hereby also declare that I have fully understood the Policy coverage details and also the Services and rules
and regulation of Indian Medical Legal Services (IMS).
Signature
Doctor's Signature
Name of the Exec./Officer....................................................
1. Name of Proposer :
2. Address :
Residence :
Business :
3. Date of Birth
4. Professional Qualification
Qualification
Year
College/University
5. Medical registration
6. Are you a member of Medical Association /
Council, if so please state and address of
such Association / Council with membership
No., Year etc.
7. Are you general physician / Surgeon / dentist
specialist Physician / anesthetist (In case of
Specialist state the exact line in which you
specialize)
EXTRA FACILITIES
8. How long have you been practicing
9. State the address of your clinic / chamber
10. Are you attached to/or attending as a visiting
physician/surgeon in any Hospital/nursing
Home/Clinic etc.
11. State the average number of patients you care
attending per day.
12. Has any claim been made upon you are or
legal proceeding instituted of threatened
against you by patients in respect of your
treatments etc. if so, give details
13. Has the risk previously been Insured ? If so
with what Company
14. Has any Company
(a) declined your proposal
(b) required an increased premium
(c) refused to renew
(d) cancelled such a policy
15. Limit of Indemnity required
(1) for any one accident :
(2) for any one year :
Annual Income I hereby declare that the above statements and particulars are true and I have not suppressed or misstated any
material facts, that at the present time I have no reason to anticipate any claim brought against me for any
negligent act, error or omission on any part and agree that this declaration shall be the basic of the contract
between me and the Company. I also agree that the indemnity under this insurance shall not be available for
claims arising out of negligence error or omission or misconduct committed PRIOR to commencement of this
insurance or after its EXPIRY.
Date ..............................
Agency ..........................
........................................
Signature of Proposer
Liability to the Company does not commence until acceptance of the proposal has been intimated by the Company.
New India Assurance Company Ltd.
Regd. Office : 87, MG Road, Fort, Mumbai - 400001
Regional Office II : 10th Floor, Core-I, Laxmi Nagar, Distt. Centre, Delhi-110092
1. Name of Proposer :
2. Address :
Residence :
Business :
3. Date of Birth
4. Professional Qualification
Qualification
Year
College/University
5. Medical registration
6. Are you a member of Medical Association /
Council, if so please state and address of
such Association / Council with membership
No., Year etc.
7. Are you general physician / Surgeon / dentist
specialist Physician / anesthetist (In case of
Specialist state the exact line in which you
specialize)
8. How long have you been practicing
9. State the address of your clinic / chamber
10. Are you attached to/or attending as a visiting
physician/surgeon in any Hospital/nursing
Home/Clinic etc.
11. State the average number of patients you care
attending per day.
12. Has any claim been made upon you are or
legal proceeding instituted of threatened
against you by patients in respect of your
treatments etc. if so, give details
13. Has the risk previously been Insured ? If so
with what Company
EXTRA FACILITIES
14. Has any Company
(a) declined your proposal
(b) required an increased premium
(c) refused to renew
(d) cancelled such a policy
15. Limit of Indemnity required
(1) for any one accident :
(2) for any one year :
Annual Income I hereby declare that the above statements and particulars are true and I have not suppressed or misstated any
material facts, that at the present time I have no reason to anticipate any claim brought against me for any
negligent act, error or omission on any part and agree that this declaration shall be the basic of the contract
between me and the Company. I also agree that the indemnity under this insurance shall not be available for
claims arising out of negligence error or omission or misconduct committed PRIOR to commencement of this
insurance or after its EXPIRY.
Date ..............................
........................................
Agency ..........................
Signature of Proposer
Liability to the Company does not commence until acceptance of the proposal has been intimated by the Company.