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: IAN Member IAN Member's Spouse / Children

Life Membership No (LM-XXX) * :
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 * : ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

MBBS * : ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

DM/M.Ch :   ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020	MD/MS :       ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020	MBBS * :       ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Speciality :   ----Select----   DM - Clinical Pharmacology DM - Clinical Haematology DM - Pulmonary Medicine DM - Neuro Radiology DM - Nephrology DM - Neonatology DM - Oncology DM - Gastroenterology DM - Cardiology DM - Neurology DM - Rheumatology DM - Endocrinology DM - Clinical Immunology DM - Pul. Med. & Critical Care Med. DM - Cardiac-Anaes. DM - Haematology Pathology/Hematopthology DM - Medical Genetics DM - Hepatology DM - Immunology DM - Child & Adolescent Psychiatry DM - Pediatrics Gastroenterology DM - Pediatrics Cardiology DM - Paediatric Anaesthesia DM - Neuro Anaesthesia DM - Paediatric Nephrology DM - Reproductive Medicine DM - Infectious Disease DM - Virology DM - Paediatric Oncology DM - Geriatric Mental Health DM - Paediatric Hepatology M.Ch - Hand Surgery M.Ch - Gynaecological Oncology M.Ch - Pediatric Cardio-Thoracic Vascular Surgery M.Ch - Plastic & Reconstructive Surgery M.Ch - Hepato Pancreato Biliary M.Ch - Urology/Genito-Urinary Surgery M.Ch - Hand & Micro Surgery M.Ch - Burns & Plastic Surgery M.Ch - Endocrine Surgery M.Ch - Oncology M.Ch - Vascular Surgery M.Ch - Cardio Thoracic Surgery M.Ch - Cardio Thoracic and Vascular Surgery M.Ch - Neuro Surgery M.Ch - Paediatric Surgery M.Ch - Plastic Surgery M.Ch - Surgical Gastroenterology/G.I. Surgery M.Ch - Surgical Oncology M.Ch - Thoracic Surgery M.Ch - Urology	Speciality :   ----Select---- MD - Thoracic Medicine MD - Sports Medicine MD - Family Medicine MD - Radio Diagnosis/Radiology MD - Aviation Medicine/Aerospace Medicine MD - Tuberculosis & Respiratory Diseases / Pulmonary Medicine Anaes. & Critical Care Med. MD - Medical Genetics MD - Rheumatology Master of Family Medicine MD - Palliative Medicine Master of Public Health (Epidemiology) MD - Blood Banking & Immuno. Haem./Imm. Haem. & Blood Trans. MD - Tropical Medicine MD - Maternity & Child Health MD - Pulmonary Medicine MD - CCM MD - P.S.M MD - TB & Chest MD - Skin & VD & Lepxsy MD - MD- Skin & VD MD-Transfusion Medicine MD - Immuno Haematology & Blood Transfusion MD - Medicine Doctor of Medicine M.D. Masters of Physician MD - Pharmacology and Therapeutics MD - Pathology & Microbiology MD - Emergency Medicine MD - R & D MD - Anaesthesiology MD - Anatomy MD - Aviation Medicine MD - Bio-Chemistry MD - Bio-Physics MD - Community Medicine MD - Dermatology MD - Forensic Medicine/Forensic Medicine & Toxicology MD - General Medicine MD - Community Health Administration MD - Geriatrics MD - Hospital Administration MD - Health Administration MD - Lab Medicine MD - Microbiology MD - Nuclear Medicine MD - Obstetrtics & Gynaecology MD - Ophthalmology MD - Paediatrics MD - Pathology MD - Dermatology , Venereology & Leprosy MD - Pharmacology MD - Physiology MD - Physical Medicine & Rehabilitation MD - Psychiatry MD - Radio Diagnosis MD - Radiology MD - Radiotherapy MD - Social & Preventive Medicine / Community Medicine MD - Tuberculosis & Respiratory Diseases/Medicine MD - Venereology MS - Obstetrics and Gynaechology MS - Orthopaedics MS - Anatomy MS - ENT MS - General Surgery MS - Ophthalmology MS - Anaesthesia MS. - MS. Medicine MS - Neuro Surgery MS - Traumatology and Surgery MD/MS - Anatomy MD/MS - Ophthalmology MD/MS - Obstetrtics & Gynaecology	Speciality * :

Medical Council Registration Details :

Registration No. * :

State * : ---- Select ---- Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

DM * : ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020	MBBS * : ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
DM/M.Ch : ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020	MD/MS :      ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020	MBBS * :       ----Select----   1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Upload your first Medical Council Reg. Certificate * :

* Only .jpg and .png file format is allowed and max file size allowed is 2MB.

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:
Duration of Practice (in years) * :
Are you attached to any Hospital or Nursing Home, etc.? If yes, give details:
Are you serving any organization? If yes, please specify:
Average number of patients out per day * :
Any pending Medico legal proceedings against you?	Yes        No
Any likelihood of future Medico legal proceedings?	Yes        No
Details of Previous Insurance, if any ?

Choose Insurance Policy Type * :

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

DD Number * :	Bank Name * :
Branch Name * :

Account Number * :	Bank Name * :
Account Holder Name * :	Branch Name * :
Transaction No. * :	Transaction Date * :

You will be redirected to payment gateway....