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PROFESSIONAL INDEMNITY PROPOSAL FORM FOR IAN MEMBERS/IAN MEMBER'S SPOUSE/CHILDREN
a) Are you attached to any Hospital or Nursing Home, etc.? If yes, give details:
b) Are you serving any organization? If yes, please specify:
a) Any pending Medico legal proceedings against you?
b) Any likelihood of future Medico legal proceedings?
Choose Insurance Policy type:
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 United India Insurance Company Limited.
Mode of Payment
DD/Cheque to be sent to IAN Secretariat (with name, IAN membership number and contact number) written on the back (Address: Dr. Gagandeep Singh, Professor & Head, Dept. of Neurology, DMC & H, Ludhiana- 141001)
