Legal Support Proposal Form for State Practitioners

Section A: Personal Details Of Proposer

Section B: Professional Credentials

1. Please state your relevant qualification and experience(Required)
Qualification(s)
Institution
Year Achieved
 

Section C: Insured's Professional Activities

1. Please select your current title for which you require cover:(Required)
3. Please indicate the % time spent in your professional capacity in:(Required)
State hospitals
Private practice
Percentage (%) of 100
4. How many hours a week doo you spend in:(Required)
State hospitals
Private practice
Percentage (%) of 100
Note: We recommend that you keep a record, including copies of letters and this Proposal Form, of all information supplied to us for the purpose of entering into this contract.(Required)
Signed (Add First Name & Surname)
Date
This field is for validation purposes and should be left unchanged.