Medical Malpractice Insurance

Proposal Form

1. Personal Details

(a) Full Name : .

(b) Date of Birth : .. Nationality:

(c) Iqama /ID No : ... Sex: .

(d) Contact Tel. # : Res: . Mobile: .

(e) E-mail : .

(f) Postal Address : .

2. (a) Name of Hospital/Clinic employed at : .

(b) Position held there : ..

(c) Medical Profession : ..

(d) Date you have started this employment : .

(e) Basic Salary per month in SAR :

3. Qualifications
Degree Date University Location
..
..
4. Please give brief description of present Duties and Activities:
..
..
..
5. Full details of previous experiences (Including positions held and dates)
Position Period Activities Location
..
..
..
6. Limit of Liability required
(a) SR. 100,000 any one claim and SR. 100,000 in the annual aggregate Yes No
(b) SR. 250,000 any one claim and SR. 250,000 in the annual aggregate Yes No
(c) SR. 500,000 any one claim and SR. 500,000 in the annual aggregate Yes No
(d) SR 500,000 any one claim and SR. 1,000,000 in the annual aggregate Yes No
(e) SR. 1,000,000 any one claim and SR. 2,000,000 in the annual aggregate Yes No

7. Type of Cover required (please tick one only)

A. Medmal Basic : (Private Right only)
B. Medmal Plus : (Private Right, Letter of Guarantee & Income Support)

P. O Box 7076 Jeddah 21462 Tel. 02- 6633222 Fax. 02- 6614830
E-mail.info@acig.com.sa www.acig.com.sa
8. Are you licensed in Saudi Arabia for the medical activities? If yes,
please attach the copy.

Yes No

9. (a) Estimated number of patients expected per year:

(b) Estimated number of operations to be completed per year:

10. Has any Proposal for Medical Malpractice Insurance ever been declined or Yes No
has such Insurance been cancelled or renewal refused or special terms
imposed? If yes, please give details.

11. Claims History
(a) Have any claims or suit for negligence, error or omission been made Yes No
against you?
(b) Are you aware of any circumstances which may result in any such Yes No
claim being made against you?
(c) Are you aware of any such or suits for negligence, error or omission Yes No
been made against any of your partners, assistants, nurses or
technicians?
If your answer to any of above is YES, please provide details.


Do you have Medical Malpractice Insurance before? If yes, please give
details.
12.

Payment Term : Premium to be paid in full at policy inception. For any further
Information please
contact:
Declaration : I declare that the statements and particulars in this proposal AIJAZ AHMED
are true and that I have not misstated or suppressed any material facts. I Sales
agree that this proposal, together with any other information supplied by us Executive
shall form the basis of any contract of Insurance effected thereon and shall TEL 4852626
be incorporated therein. I undertake to inform Insurers of any material Ext 4430
alteration/ change to these facts whether occurring before or after Fax
completion of the Contract of Insurance. Signing this Proposal Form does 01-4852727
not bind the Proposer to complete this insurance. MOBILE
0590702812
Policy Period aijazamd@
1 Year Yes No 3 Years Yes No 5 Years Yes No yahoo.com
(or)
From To.. aijaz@acig.co
m.sa
Signature.Date..

Bank Account Details : Name - ALLIED COOPERATIVE INSURANCE GROUP

A. Bank : The National Commercial Bank IBAN: SA02 100000 A/C 62211856000109
B. Bank : RIYAD BANK IBAN : SA85 2000000 A/C 1013317219940
C. Bank : AL RAJHI BANK IBAN : SA24 80000 A/C 462 6080 1999 5555

For Office USE ONLY SALES EXECUTIVE REMARKS

Initial Remarks

P. O Box 7076 Jeddah 21462 Tel. 02- 6633222 Fax. 02- 6614830
E-mail.info@acig.com.sa www.acig.com.sa