Client Registration Cum Insurance Proposal Form

Insured Type:

Name of Doctor / Medical Establishment:

Residence Address House No./ Flat No. / Block

Street / Road / Locality

District

State

Pin Code

Hospital / Clinic Address House No./ Flat No. / Block

Street / Road / Locality

District

State

Pin Code

Mobile Number* Only 10 digit without country code

Alternate Mobile Number Only 10 digit without country code

Email example@example.com

Date of Birth*

Wedding Date

ID Proof (Choose Option)*

ID Number

Speciality*

Other Speciality

Qualification / Degree

Registration Number

Year

Medical Council

Are You a Visiting Physician / Consultant?

Name the Hospitals / Clinics you are associated with

Have any claims been made upon you or legal proceedings instituted or likely to be instituted?

How long you have been practising?

State the average no. of patients you are attending per day

Extension for unqualified staff required?

Your estimated annual income in Rs.

Registration Number of Hospital / Diagnostic Centre

No. of Beds

Annual OPD

Annual IPD

Facilities available

Total No. of doctors employed in various speciality

Registration Number of Hospital / Diagnostic Centre

Annual OPD

Facilities available

Total No. of doctors employed in various speciality

Insurance Cover required*

Please give 2 references of Doctors to whom you would recommend our services

Doctor's Name	Contact Ditails	Location

Total Premium

Tenure*

Amount Paid

Mode of Payment and Cheque / Ref. No.

Relationship Manager Name*

Relationship Manager Email ID

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I agree and hereby declare that the above statement and particulars are true and I have not suppressed or mis-stated any material and that at the present time I have no reason to anticipate any claim being brought against me for any negligence, etc. error or omission on my part and agree that this negligence, error or omission or mis-conduct is committed prior to the commencement of this insurance. I have also understood the terms and conditions of membership of PROTECTPLUS Services Ltd.

Date and Time of Submission

Place of Submission*