Limits of FOGSI Indemnity Policy ( FOR OBST & GYN PRACTICE & PROCEDURES ONLY) Premium Sheet for Different Categories of Doctors Limits of Indemnity

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Limits of FOGSI Indemnity Policy ( FOR OBST & GYN PRACTICE & PROCEDURES ONLY) Categories of Doctors Premium Sheet for Different Categories of Doctors Limits of Indemnity Rs.20 Lacs anyone Rs.40 Lacs anyone Rs.60 Lacs anyone year (multiple year (multiple year (multiple aggregating to 20 aggregating to 40 aggregating to 60 Rs.20 Lacs incident Rs.40 Lacs incident Rs.60 Lacs incident Rs.80 Lacs anyone year (multiple aggregating to 80 Rs.80 Lacs incident Rs.1 Crore anyone year (multiple aggregating to 1 Crore) Rs.1 Crore incident Individual Doctors [ A ] Resident Doctors without any Private Practice / Consultancy [ B ] Total Premium Total Premium Total Premium Total Premium Total Premium Category : A : Rs.3,648/- Category : B : Rs.912/- Doctors who own Medical Establishment, do not Render Medical Service Elsewhere. Hospitals with beds upto (For Obst & Gyn practice & procedures) 10 Beds 20 Beds Category : C1 : Rs.6,794/- Category : C2 : Rs.7,706/- [ C ] 30 Beds Category : C3 : Rs.8,618/- 40 Beds Category : C4 : Rs.9,530/- Doctors who own Medical Establishments, Render Medical Service in any other Hospitals also Hospitals with beds upto (For Obst & Gyn practice & procedures) [ D ] 10 Beds Category : D1 : Rs.10,442/- 20 Beds Category : D2 : Rs.11,354 /- 30 Beds Category : D3 : Rs.12,266/- 40 Beds Category : D4 : Rs.13,178/- Category : A1 : Rs.7,296/- Category : B1 : Rs.1,824/- Category : C11 : Rs.12,677/- Category : C12 : Rs.13,589/- Category : C13 : Rs.14,501/- Category : C14 : Rs.15,413/- Category : D11 : Rs.19,973/- Category : D12 : Rs.20,885/- Category : D13 : Rs.21,797/- Category : D14 : Rs.22,709/- Payment : Demand Draft in favour of FOGSI-Indemnity. It includes 14% Govt.Service Tax. Category : A2 : Rs.10,944/- Category : B2 : Rs.2,736/- Category : C21 : Rs.19,471/- Category : C22 : Rs.21,295/- Category : C23 : Rs.23,119/- Category : C24 : Rs.24,943/- Category : D21 : Rs.30,415/- Category : D22 : Rs.32,239/- Category : D23 : Rs.34,063/- Category : D24 : Rs.35,887/- Category : A3 : Rs.14,884/- Category : B3 : Rs.3,721/- Category : C31 : Rs.25,861/- Category : C32 : Rs.27,721/- Category : C33 : Rs.31,442/- Category : C34 : Rs.31,442/- Category : D31 : Rs.40,744/- Category : D32 : Rs.42,605/- Category : D33 : Rs.44,466/- Category : D34 : Rs.46,326/- Category : A4 : Rs.18,605/- Category : B4 : Rs.4,651/- Category : C41 : Rs.32,791/- Category : C42 : Rs.34,850/- Category : C43 : Rs.38,372/- Category : C44 : Rs.41,163/- Category : D41 : Rs.51,396/- Category : D42 : Rs.54,186/- Category : D43 : Rs.56,977/- Category : D44 : Rs.59,768/- Correspondence Address : FOGSI Office, C-5,6,7,12,13, 1 st Floor, D-Wing Entrance, Trade World, Kamala City, Senapati Bapat Marg, Lower Parel, West, Mumbai 400013. Maharashtra Contact Numbers : (022) 24951648 / 24951654 Email Id : fogsischemes@gmail.com Note : Please send your Contact Numbers and Email ID.

yaunaa[tod [MiDyaa [nsyaaoronsa kmpnai ilaimatod idvaijanala Aa^ifsa nam.4, valakna [nsyaaoronsa ibaldimga, 1laa maalaa, 77,vaIr narimana raod, caca-gaot, maumba[- 400020. UNITED INDIA INSURANCE CO. LTD. Divisional Office No.4,Vulcan Insurance Building,1 st Floor, 77,Veer Nariman Road,Churchgate,Mumbai 400020. Category PROPOSAL FORM FOR DOCTORS AND MEDICAL PRACTITIONERS GYNAECS & OBSTETRICIANS INDIVIDUAL DOCTORS 1. Name of the Doctor Member : 2. Address for Correspondence : 3. Email ID : 4. All Contact Numbers : 5. Name of the Affiliated Society : 6. Professional Qualification and the year of such Qualification : 7. Medical Registration Number : 8. Are you a member of any Medical Association / Council, if so, please state Name and Address of such Association / Council with Membership Number : 9. Are you resident doctor without any Private Practice or Consultancy? : 10. Has any claim been made upon you or Legal Proceedings institute or likely to be instituted against you by patients in respect of your treatment etc. If so, please give details : 11. Have you been previously insured for the subject risk? If so, please give full details : 12. Limit of Indemnity (liability) required (Please tick the option) Any One year : (Multiple aggregating to Rs.1 Crore, Rs.80 Lacs, Rs.60 Lacs, Rs.40 Lacs and Rs.20 Lacs respectively as per option chosen) OR Any One Incident : Rs.1 Crore Rs.40 Lacs Rs.80 Lacs Rs.20 Lacs Rs.60 Lacs I here declare that the above statement and particulars are true to the best of my knowledge and I have not suppressed or misrepresented any material facts and that at present time. I have no reason to anticipate any claim being brought against me for any negligent act, error or omission on my part and agree that this declaration shall be the basis of contract between me and the Insurer. I also agree that the Indemnity under the insurance shall not be availed for claim arising out of acts of negligence error or omission or misconduct committed prior to commencement of this insurance. Date : Place : UNDERTAKING : I hereby undertake to repay entire amount to UIIC (through FOGSI) which was paid by United India Insurance Co.Ltd., towards Defense Costs, etc. if there is a conviction against me on criminal charges. Authorised Signatory of FOGSI

yaunaa[tod [MiDyaa [nsyaaoronsa kmpnai ilaimatod idvaijanala Aa^ifsa nam.4, valakna [nsyaaoronsa ibaldimga, 1laa maalaa, 77,vaIr narimana raod, caca-gaot, maumba[- 400020. UNITED INDIA INSURANCE CO. LTD. Divisional Office No.4,Vulcan Insurance Building,1 st Floor, 77,Veer Nariman Road,Churchgate,Mumbai 400020. Category PROPOSAL FORM FOR MEDICAL ESTABLISHMENTS ERRORS AND OMISSIONS INSURANCE FOR OBST & GYN PRACTICE & PROCEDURES ONLY 1. Name of the Doctor Member : 2. Name of the Medical Establishment & Address : 2. Address for Correspondence : 3. Email ID : 4. All Contact Numbers : 5. Name of the Affiliated Society : 6. Year in which established & Registration Number of Hospital : 7. Names and Addresses of Owners. Directors / Partners : a) b) c) 8. Have you complied with all the statutory Rules / Regulations relating to your establishment : 9. Whether the Establishment is meant only for the Purpose of Gynaecological / Obstetric treatment? If not please specify : 10. Please specify all the facilities available like X-Ray, Scanning, Pathology etc (For Information only) : 11. State number of beds maintained : 12. Please state the number of Unqualified Staff : 13. Give details of Radioative treatment facilities Specify materials used and precautions taken Further for such usage. : P.T.O.

- 2-14. Details of any Claims lodged against the Proposer in the past on account of service rendered by Your Establishment : 15. Details of any event likely to give rise to a liability claims against you a Future date : 16. State Limit of Indemnity (liability) required (Please tick the option) Any One year : (Multiple aggregating to Rs.1 Crore, Rs.80 Lacs, Rs.60 Lacs, Rs.40 Lacs and Rs.20 Lacs respectively as per option chosen) OR Any One Incident : Rs.1 Crore Rs.40 Lacs Rs.80 Lacs Rs.20 Lacs Rs.60 Lacs I here declare that the above statement and particulars are true to the best of my knowledge and I have not suppressed or misrepresented any material facts and that at present time. I have no reason to anticipate any claim being brought against me for any negligent act, error or omission on my part and against the company and agree that this declaration shall be the basis of contract between me and the Insurance company. I also agree that the Indemnity under the insurance shall not be availed for claims arising out of acts of negligence, error or omission or misconduct committed prior to commencement of this insurance. OR for claims other than Obst & Gyn practice & procedures. Date : Place : UNDERTAKING : I hereby undertake to repay entire amount to UIIC (through FOGSI) which was paid by United India Insurance Co.Ltd., towards Defense Costs, etc. if in case there is a conviction against me on criminal charges. Authorised Signatory of FOGSI

This is for members who have Indemnity Policy and want to transfer liability. This consent form has to be filled. You have to attach last 3 years indemnity policy with the proposal form and one time loading or 30% on the premium. Consent Form There in no prior on pending litigation and I have no knowledge of any situation which may give rise to a claim. Name : Address : Contact Numbers : Signature : Date :

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