Details Of Company

1. Name of Company
2. ADDRESS of Company
3. Incorporation/Registration No
4. Date of Registration
5. State of Registration
6. Country of Registration
7. Operating Phone No(S)
8. E-MAIL Address
9. Website
10. Fax(if available)
11. Tax Identification No. (TIN
12. Bank Verification No. (BVN)
13. MEANS OF IDENTIFICATION please select NATIONAL ID DRIVER's LICENSE INT'L PASSPORT VOTERS CARD
14. IDENTIFICATION NUMBER
15. ISSUING AUTHORITY
16. DATE OF ISSUE
17. DATE OF EXPIRY
18. Period of Cover from to be delivered
19. Area of Specialization
20. NO. OF PERMANENT STAFF
21. NO. OF MEDICAL PROFESSIONALS
22. 1. 1. Name of Chief Medical Director (CMD)
       2. Qualifications
       3. Date of Birth
       4. Specialty/ies
       5. Years in continuous practice
       6. Passport/Drivers Licence No
       7. Date of issue
    2. 1. Full Home Address
       2. Hospital

    3. Which Professional bodies in Nigeria do you belong to? Please state your membership status – Member, Fellow, Associate

       BODY
       

       STATUS
       

    4. Have you ever held or do you hold a Professional Indemnity Insurance cover with another Insurer? If yes please state with whom and for how long

       please select Yes No
       If yes please state with whom and for how long
    5. Do you practice outside Nigeria please select Yes No
       
    Have you or any staff of the centre/institution ever faced a disciplinary committee for: professional misconduct? please select Yes No
    if yes, please give details sheet