Professional Indemnity Insurance Proposal Form

I. General Data

1. Name of health Institution: (herein referred to as "the Proposer")

2. Business Address

3. Email

4. Mobile No. (Main)

Mobile No. (Alternative)

5. Date of establishment (DD/MM/YYYY)

6. Are you politically exposed?

Yes

7. Is the Proposer

a) Approved by a public authority (KMPDC/COC)?

Yes

b) a member of a hospital association?

Yes

8. Is the proposer maintained in whole or in part by public or private funds or endowment (Public/Private/FBO) ?

Yes

II. Nature and volume of your present and foreseeable future activities

1. Brief description of the Proposer's activities (e.g. operations of a hospital, clinic,nursing home, sanatorium)

2. Estimated Gross Annual Income (please indicate currency)

3. Number of patients per year

4. Approximate division of patients between

a) General	%	e) Orthopaedic	%
b) Surgical	%	f) Dental	%
c) Gynaecological and Obstetrical	%	g) Psychiatric	%
d) Paediatric	%	h) Any others classes	%

5. Number of doctors employed (including doctors in clinics) in each of the following classifications

Classification	Number
a) Medical Officers
b) Clinical Officers
c) Anaesthetists
d) Gynaecologists
e) Pharmacists/Pharmtech
f) Surgeons
g) Lab Technologists
h) Radiologists
i) Ophthalmologists
j) Dentists
k) Physicians
l) Interns (licensed and unlicensed)
m) Others (please specify)

6. Number of medical assistants (pharmacists, laboratory technicians, etc.)

7. Number of nurses

8. Number of beds (including for maternity cases)

9. Does the Proposer own or operate X-Ray machines, lasers, Ultrasound machines or similar equipment?

Yes

10. Does the Proposer use radioactive materials?

Yes

11. Does the Proposer operate a blood bank?

Yes

a) For own purpose

b) For supply to other parties

III. Previous insurance/claims

1. Has the Proposer previously been insured?

Yes

Name of Insurer	Policy Period	Limit of Indemnity (KShs.)

2. Has a previous application been declined?

Yes

Has a previous insurance:

a) Required increased premium?

Yes

b) Required special restrictions?

Yes

c) Been terminated/not been renewed by an Insurer

Yes

3. Have any claims or suits for malpractice been made during the past five years against the proposer?

Yes

4. Is the proposer aware of any circumstances or incidents which may result in a claim or claims against him?

Yes

IV. Indemnity Required (Minimum 500,000)

1. Limit in the annual agregate (KShs.)

2. Limit in any one claim (KShs.)

3. Deductible each and every claim to be borne by Insured (KShs.)

V. Document Uploads

Upload KRA PIN

Accepted formats: PDF, JPG, PNG (Max 5MB)

Facility License

Accepted formats: PDF, JPG, PNG (Max 5MB)

Upload ID (Front and Back on same file))

Accepted formats: PDF, JPG, PNG (Max 5MB)

Facility Registration

Accepted formats: PDF, JPG, PNG (Max 5MB)

DECLARATION

I/We declare that to my/our knowledge that the answers and particulars given in this Proposal Form are true and complete and that I/we have not withheld any material information. I/We have also read and understood that this Proposal Form and Declaration shall be the basis of the Contract between me/us and the Insurance Company.

DATA PRIVACY

I/ We willingly provide my/ our personal information in this Proposal Form and consent its use as prescribed by the Data Protection policy of the specific insurance company i am sending this proposal to (The policy is available on their website) and in accordance with Data Protection Act, 2019.

Signing this Proposal Form does not bind the Proposer or Underwriter to complete this insurance.

Date of Completion of Proposal Form (DD/MM/YYYY)

For and on behalf of (insert name of firm)

Signature of Partner or Principal

Processed by DUNIK INSURANCE AGENCY-Regulated by IRA

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

FOR HOSPITAL MALPRACTICE

I. General Data

II. Nature and volume of your present and foreseeable future activities

III. Previous insurance/claims

IV. Indemnity Required (Minimum 500,000)

V. Document Uploads

DECLARATION

DATA PRIVACY