{"id":2499,"title":"Professional Indemnity Insurance Proposal Form For Doctor's Indemnity","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/professional-indemnity-insurance-policy/PI_proposal_Form-Doctor.pdf","sha256":"d51fe1b054d799f08f8e4937a0da6eeb18a829bd8cde124de6b14269397a2c4e","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by doctors to apply for professional indemnity insurance coverage. The proposer (doctor) fills it to provide personal, professional, and risk-related information for underwriting.","notes":["Answer all questions fully and accurately to avoid claim rejection or policy avoidance.","Attach separate sheets if space is insufficient for any answers.","Keep policy updated with contact and bank details for faster service.","Use the Caringly Yours App, WhatsApp, call center, email, or website to update details.","Original bills and documents may be required for claims processing upon demand.","The form includes a disclaimer about confidentiality and virus protection for email communications."],"title":"Professional Indemnity Insurance Proposal Form For Doctor's Indemnity","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name as the proposer","type":"text","label":"Name of the Proposer ( in full )","options":[],"required":true,"pdf_field":""},{"help":"Enter your office correspondence address","type":"text","label":"Correspondence address of office","options":[],"required":true,"pdf_field":""},{"help":"Enter your residential address","type":"text","label":"Residential address","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Enter the name as per your bank records","type":"text","label":"Name as pr Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter your bank's name","type":"text","label":"Name Of Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your bank branch's IFSC code","type":"text","label":"IFSCCode","options":[],"required":null,"pdf_field":""},{"help":"Confirm if you accept payments in this bank account","type":"yes-no","label":"I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide your e-lA number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-lA No. to deposite your insurance policy.","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to open an e-lA account","type":"choice","label":"Do you want to open e-lA account","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Customer Details","fields":[{"help":"Select if you are an existing customer","type":"choice","label":"Are you an exisiting customer of Bajaj General?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide your existing PID or Policy number","type":"text","label":"If Yes. Please provide PID No: /Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Confirm if your KYC details remain unchanged","type":"checkbox","label":"I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Professional Qualifications and Practice Details","fields":[{"help":"List your professional qualifications and the year obtained","type":"text","label":"Professional Qualifications and the year of these qualification","options":[],"required":true,"pdf_field":""},{"help":"Specify your branch of medicine","type":"choice","label":"In which branch of medicine viz. Allopathy/ Homeopathy , please specify.","options":["Allopathy","Homeopathy","Other"],"required":true,"pdf_field":""},{"help":"Enter your medical registration number","type":"text","label":"Medical Registration No:","options":[],"required":true,"pdf_field":""},{"help":"Enter the year you registered as a medical practitioner","type":"date","label":"Year Of Registration","options":[],"required":true,"pdf_field":""},{"help":"State your years of practice","type":"text","label":"How long have you been practising","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you are a member of any medical council","type":"yes-no","label":"Are you member of any Medical Council","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of the medical council membership","type":"text","label":"If so, please mention the name & address of such association/ council with Membership no.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Select your business constitution type","type":"choice","label":"Constitution Details","options":["Partnership Firm","Limited Liability/Partnership Firm","NGO/NPO","Company","Trust","Society","Section 8 Company","Proprietorship Firm","Others (Please specify)"],"required":true,"pdf_field":""},{"help":"Provide DARPAN registration details if applicable","type":"text","label":"Provide DARPAN Portal Registration, if applicable","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Professional Practice Details","fields":[{"help":"Select your professional category","type":"choice","label":"Are you a General Practioner/ General Physician/ Pathologost/ radiologist/ Consulting Physician/ Anasthesist/ Plastic Surgeon","options":["General Practitioner","General Physician","Pathologist","Radiologist","Consulting Physician","Anesthetist","Plastic Surgeon","Other"],"required":true,"pdf_field":""},{"help":"Specify your specialization if applicable","type":"text","label":"If Specialist, Mention your area of Specialisation","options":[],"required":false,"pdf_field":""},{"help":"Indicate if facilities have regular maintenance contracts","type":"yes-no","label":"Are these facilities being maintained through regular service contracts with the manufacturers/ specialised serving agencies.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide employee details operating facilities on a separate sheet","type":"text","label":"If these facilities are operated by employees please state their (1) names (2) Technical Qualifications (3) Experience & (4) Name of the facility maintained against (Please use a separate sheet )","options":[],"required":false,"pdf_field":""},{"help":"List unqualified personnel and facilities if coverage extension is desired","type":"text","label":"Do you wish to extend the policy cover to personnels unqualified to maintain these facilities, please mention their names alongwith facility operated","options":[],"required":false,"pdf_field":""},{"help":"Provide employee details and supervision","type":"text","label":"Specify No. of Employees , their job specifications , their experience and nature of your supervision","options":[],"required":false,"pdf_field":""},{"help":"Provide details of visiting attachments if any","type":"text","label":"Are You attached to /or attending as a visiting physicia / surgeon in any hospital / nursing home/clinic etc., If Yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you are employed by any organization","type":"yes-no","label":"Are you in service with any organisation?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if the organization has errors & omissions insurance","type":"yes-no","label":"Are They Covered under a Medical Establishments - Errors & omissions Policy","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide average daily patient count","type":"number","label":"State the average No. of Patients you are attending per day","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you currently have professional indemnity insurance","type":"yes-no","label":"Does the Proposer currently hold any Professional Indemnity Insurance?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide renewal date of current policy","type":"date","label":"If 'Yes' state Renewal Date","options":[],"required":false,"pdf_field":""},{"help":"State the indemnity limit of current policy","type":"amount","label":"Limit of Indemnity:","options":[],"required":false,"pdf_field":""},{"help":"Provide retroactive date if applicable","type":"date","label":"Retroactive Date:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if loss of documents cover is required","type":"yes-no","label":"Please indicate if the following covers are required: i) Loss of Documents","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Confirm if documents are stored in fireproof cabinets","type":"yes-no","label":"If 'Yes', does the Proposer keep documents in fire proof cabinets?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if libel and slander cover is required","type":"yes-no","label":"ii) Libel and Slander","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if dishonesty of employees cover is required","type":"yes-no","label":"iii) Dishonesty of Employees","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance History and Claims","fields":[{"help":"Indicate if any insurer has declined or terminated your insurance","type":"yes-no","label":"Has any insurer in respect of the risks to which this proposal relates ever declined a proposal, refused renewal or terminated an insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of insurer actions","type":"text","label":"If 'Yes' in either case, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any claims have been made against you or associates","type":"yes-no","label":"Has any claim been made against the Proposer or any partner, director, consultant or employee for neglect, error or omission in relation to professional duties?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide detailed information on claims or losses","type":"text","label":"If 'Yes' in either case, please give details separately of the circumstances of each incident including any amounts paid and the estimated potential cost of the incident.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any disclosed circumstances","type":"text","label":"If 'Yes', please give details separately","options":[],"required":false,"pdf_field":""},{"help":"Specify the indemnity amount you require","type":"amount","label":"What is the amount of Indemnity required?","options":[],"required":true,"pdf_field":""},{"help":"Provide alternative indemnity amounts if desired","type":"amount","label":"Please state any alternative amounts for which a quotation is required","options":[],"required":false,"pdf_field":""},{"help":"Specify your deductible/contribution per claim","type":"amount","label":"Please state the amount the Proposer wish to contribute towards each and every claim","options":[],"required":true,"pdf_field":""},{"help":"Provide alternative deductible amounts if desired","type":"amount","label":"Please state any alternative amounts for which a quotation is required","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select your mode of payment","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Cash","Other"],"required":true,"pdf_field":""},{"help":"If payment by cheque, specify who gave the cheque","type":"choice","label":"Cheque - Given by","options":["Spouse","Father","Mother","Son/Daughter","Employer / Employee","Financier"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign here as partner or director","type":"signature","label":"Signature of Partner / Director","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Declare if you or relatives are Politically Exposed Persons","type":"choice","label":"Declaration - Physical Proposal Form: Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Sign to confirm understanding and agreement","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Provide name of witness","type":"text","label":"Name of Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Declare any physical disability","type":"yes-no","label":"Disability Declaration: Any Physical deformity or handicap","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide disability details and certificate info","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised representative","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent"}],"deadlines":[],"applies_to":"Professional Indemnity Insurance for doctors","attachments":["Separate sheet if insufficient space to provide relevant information","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The statements made in this proposal are true and complete and form the basis of the insurance contract.","Signing this form does not bind the proposer to complete the insurance.","No person shall offer or accept rebates on commission or premium except as allowed by the insurer's published prospectus.","Non-compliance with rebate provisions may result in penalties up to ten lakh rupees.","Consent is given to verify identity/address through official registries for KYC purposes.","Premiums are declared to be paid from legally acquired sources.","Consent is given to share personal data with group companies for insurance and related services.","The proposer confirms understanding of the form's content and particulars, including through vernacular explanation if needed.","Agent/intermediary declares having explained the form contents to the proposer and understands the consequences of untrue statements or non-disclosure."],"dropped_labels":13},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"careforyou@bajajgeneral.com","label":"Customer Service Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"in a new tab\nBajaj General Insurance Limited\nTollfree: For sales :\n1800-209-0144\nFor service :\n1800-209-5858\nEmail id:\ncareforyou@bajajgeneral.com\nFor senior citizens:\nseniorcitizen@bajajgeneral.com\nFor senior citizens:\n1800-209-5858\nFax no:\n020-30512246\nRegistered","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-209-5858","label":"Service Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"Careers\nBecome\n                                An Agent\nAwards\nUpdate KYC\nMY ABHA\nBuy Policy:\n1800-209-0144\n| Service:\n1800-209-5858\nService Chat:\n+91 75074 25858\nInsure\nHealth Insurance\nIndividual Health Insurance\nFamily Health Insurance\nInternational","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-209-0144","label":"Sales Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"nsurance\nSupport\nAbout Us\nCareers\nBecome\n                                An Agent\nAwards\nUpdate KYC\nMY ABHA\nBuy Policy:\n1800-209-0144\n| Service:\n1800-209-5858\nService Chat:\n+91 75074 25858\nInsure\nHealth Insurance\nIndividual Health Insurance\nFamily Healt","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-5858","label":"Customer Service Toll Free Number","level":1,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"ted servicing team to help you meet your service needs.\nCustomer Service - We're Here to Help\nDial our Toll Free Number\n1800-209-5858\nEmail us on\ncareforyou@bajajgeneral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Cha","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"ggro@bajajgeneral.com","label":"Grievance Redressal Officer Email Mr. Jerome Vincent","level":2,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"fied with the response given to you by our team, you may write to our Grievance Redressal Officer Mr. Jerome Vincent at\nggro@bajajgeneral.com\nLevel 3\nHead Customer Service\nif you are still not satisfied with the solutions provided, or have some feedback for us,","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-7073","label":"Toll free No. Intermediary","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"Here to Help\nDial our Toll Free Number\n1800-209-5858\nEmail us on\ncareforyou@bajajgeneral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Chatbot\nConnect with us on WhatsApp +91 7507425858\nFor Support\nBajaj General App\nPle","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"whatsapp","value":"+91 7507425858","label":"BOING WhatsApp Chatbot","level":null,"hours":"24x7","applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"ral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Chatbot\nConnect with us on WhatsApp +91 7507425858\nFor Support\nBajaj General App\nPlease scan and download\nMissed Call Facility\nMissed Call - 80809 45060 Short code - SMS","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/bajaj-general-insurance/2499-professional-indemnity-insurance-proposal-form-for-doctor-s-indemnity"}