PROPOSAL FORM OF PROFESSIONAL INDEMNITY POLICY FOR DOCTORS & MEDICAL

PRACTINONERS

1. Name of Dr Parth Rohitkumar Shah

Proposer 9998932811
parthshah17589@gmail.com
Mobile No. 17-5-89

Email Id.

Dob
2. Residential Address Arihant, Rayakwad Street , Vyara. Dist.
Tapi Gujarat 394650
3. A)Professional Qualification and year of such Allopathy
qualification MBBS 2012 ;DA 2016; DNB 2018
B) In which brand of medicine viz. Allopathy,
Homeopathy, Ayurveda or any other?
4. A)Medical Registration Number G 23480

B)Year of Registration 2016

Since 2016
C)How long have you been practicing?
6. A) Are you’re a General Physician, MBBS, General Anaesthesiologists
practitioner, Family Physician, radiologist, Pathologist
or
MD, Plastics Surgeon, Anaesthetist, Surgeon?

B)If any, please specify your line of specialization.

7. State the average number of patients you are 40 Patients
attending per day?
8. Are you attached to/or attending as a visiting SIDS Hospital & Research Centre, Surat
physician/surgeon in any Hospital/Nursing Occasionally few nursing home based on freelance
Home/Clinic etc. If yes please give details. call.
9. Does the proposer currently hold any Professional No
Indemnity Insurance?
If yes, please give details:
A)Renewal date
B)Limit of Indemnity
C)Retro-active date
10 Have any claims been made upon you or legal No
. proceeding instituted or likely to be instituted against
you by patients in respect of your treatment etc.? If
so, please give details.
11 Specify facilities managed or operated under your X ray No ECG
control (Yes/No) Yes_Sonography_Yes
MRI No Others

11 Limit of indemnity required 1 Cr

.
12 Period of Insurance
From / / To / /
.

I/We authorise the company and all other group of ICICI bank group and their agents to exchange, share or part with all the information
relating to my personal and financial details & f information to other ICICI bank. Group companies/Bnak/Financial Institution/Credit
Bureau/Agencies/Statutory Bodies as may be required and I/We will not hold the company and all other
group companies if ICICI bank group and their agents liable for use of information. I/We agree that the policy shall become voidable at the option of the
company, in the event of any untrue or incorrect statement, misinterpretation, non description or non disclosure in any material particlar in that
proposal form/personal statement, declaration and connected documents, or any material information has been withheld by me/us or anyone acting on
my/our behalf to obtain any benefit under this policy. I/We, the undersigned hereby declare and warrant that the above statement are true, accurate
and complete. I/We desire ti effect an insurance as described herein with the company and I/We agree that this proposal and declaration hereto shall be
be the basis of contract between me/us and the company and I/We agree to accept a policy subject to the condition prescribed by the company. I/We
agree that the issuance of policy/cover note shall be subject to realisation of premium cheque. I/We hereby agree and confirm that if the amount collected
is less than the premium quoted or revised as per changes in sum proposed for insurance or scope of cover desired by me/us, the proposal shall be
considered for acceptance for a reduced sum appropriate to the premium collected and the policy shall be finalised accordingly. I hereby confirm that I
am aware that enrolment to this product is purely voluntary and is not linked to me availing of any other facilities from the bank. I hereby confirm that
the premium towards my insurance cover will not bore by any third party entity/person(s), with the exception of my spouse, parents, grandparents,
grandparents, children, siblings or employer.

Signature

SECTION 41 OF THE INSURANCE ACT 1938

PROHIBITION OF REBATES

No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in
receipt of any kind or risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium
shown on the policy nor shall any person taking out or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the
prospectus or tables of the Insurer.

Any person making default in complying with the provisions of this Section shall be punishable with fine, which may extend to ten lacs Rupees