Medical Mal Practice Insurance |Solidarity takaful

Medical Malpractice Insurance

Basic Info

Payment Details

ID Number*

Name*

DOB*

DOB(Hijri)*

Nationality*

Mobile*

Email*

Effective Date*

Number Of Year*

Profession*

Liability*

Hospital*

I hereby declare that I am duly licensed in accordance with Saudi Arabian law to practice at the address given
I hereby declare that none of the insurance companies have
- declined my insurance application
- requested for increased premium
- imposed special restriction
- been terminated/not been renewed by an insurer
I Hereby declare that there are no any claims or suits for malpractice been made against me or any of my partners, assistants, nurses or technicians during the past five Years
I Hereby declare that I and my partners, assistants, nurses and technicians are not aware of any circumstances or incidents which may result in a claim
I declare that the statements and particulars mentioned above are true and that I have not misstated or suppressed any material facts. I agree that this information, together with any other information supplied by me, shall form the basis of any contract of insurance effected thereon. In case the above information is incorrect, Solidarity reserves the right to repudiate the claim/policy with no refund

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Payment Type

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Debit/Credit Card

Card Number*:

Name on Card*:

CVV*

Last 3 digits printed on the back of the card

Insured

National Id/Iqama/Border number :
Name :

Profession

Premium

Gross Premium :
VAT :

Additional Discount :

Net Premium :

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