Professional Indemnity Insurance - Medical Malpractice

DETAILS OF THE INSURED

INSURED NAME *

.

FIRST NAME *

LAST NAME *

Policy No.

A. DETAILS OF HOSPITAL / CLINIC

A.1 ) FULL NAME OF HOSPITAL *

A.2 ) CONTACT PERSON *

A.3 ) MOBILE *

A.4 ) EMAIL *

CONFIRM EMAIL *

A.5 ) Physicians

A.6 ) NAME OF OTHER PHYSICIANS INVOLVED,IF ANY

B. DETAILS OF CLAIMANT / PATIENT

B.1 ) FULL NAME OF THE CLAIMANT

B.2 ) FULL NAME OF THE PATIENT *

SAME AS THE CLAIMANT ABOVE

B.3 ) CURRENT CONDITION OF THE PATIENT *

DEAD

SUFFERED PERMANENT CONDITION

TEMPORARY DISABLEMENT

DISCHARGED WITH FOLLOW-UP

FULLY RECOVERED

OTHER (PLEASE SPECIFY DETAILS)

B.4 ) TYPE OF MALPRACTICE *

B.5 ) Corrective and Preventive Action / Recommendation

C. SUMMARY OF MEDICAL SERVICES

C.1 ) PLEASE SUMMARIZE THE MEDICAL SERVICES TO THE PATIENT *

C.2 ) THE CORRECTIVE OR ONGOING MEDICAL TREATMENT / RECOMMENDATION

C.3 ) OTHER PROFESSIONAL LIABILITY INSURANCE POLICIES (IF ANY)

NO IF YES PLEASE SPECIFY DETAILS

INSURANCE COMPANY

COVERAGE LIMIT (PER EACH CLAIM)

D. DATE OF CLAIM MADE OR CIRCUMSTANCE REPORTED.

D.1 ) DATE OF CIRCUMSTANCE WAS AWARE. (THE PATIENT HAS NOT MADE A CLAIM YET)

D.2 ) THE DATE OF THE CLAIM WAS FIRST MADE.(THE PATIENT HAS ALREADY MADE A CLAIM)

D.3 ) CLAIMING AMOUNT (IF KNOWN)

E. LIST OF SUPPORTING DOCUMENT

1. LICENSE TO PRACTICE MEDICINE 2. COPIES OF MEDICAL RECORDS, CERTIFICATE AND ANY MEDICAL DOCUMENT THAT IS RELEVANT TO THE CLAIM. 3. NOTICE OF CLAIM FROM THE CLAIMANT/PATIENT (IF AVAILABLE) 4. COPIES OF MEDICAL RECORDS, CERTIFICATE AND ANY MEDICAL DOCUMENT IN CASE THE PATIENT WAS TRANSFERRED TO THE OTHER HOSPITALS. 5. PROFESSIONAL INDEMNITY INSURANCE POLICY ISSUED BY THE OTHER INSURERS 6. OTHER DOCUMENTS / PHOTOS The size of each file uploaded must not exceed 10 MB and must be jpg, gif, png, pdf, doc, docx, xls, xlsx files only.

F. DECLARATION

I agree that all actions Any transactions made on an electronic system are deemed to be electronic transactions which are governed by the law under the Electronic Transactions Act, B.E. Or to continue in the future However, if there is any damage By this letter I certify that I have checked the information that Record with the best detail of my knowledge and understanding. The information is true, correct and complete in all respects.

Caution: intentionally waiving medical expenses in order to claim compensation from the company and false insurance claims It is an offense under the Criminal Code.

I confirm that this information is true in all respects and agree to the terms above.

Medical Malpractice for Physicians

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