Date of Birth *:

State *: Select State Allahabad Delhi NCR Rajasthan Punjab Uttar Pradesh

Address *:

Professional qualification *:

Medical registration number & year *:

Are you member of Any Medical Association*:

Your Specialization *:

How long have you been practicing *:

Sate the address of your clinic/ chamber *:

Has any claim been made upon you are or legal proceeding instituted or threatened against you by patients in respect of your treatment etc. If so, give details *:

Limit of identity required Sum Insured / year *:
10 Lacs   20 Lacs  50 Lacs  1 Crore 

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 being brought the against me for any negligent act, error or omission on my part and agree that this declaration shall be the basic of the contract between me and the Company.