IDA TN PROFESSIONAL INDEMNITY SCHEME

APPLICATION FORM

Personal Information

Full Name

DCI Number

IDA ID Number

Branch

Address

Indemnity Insurance

Premium Yearly with 18% GST

Date of Transfer

Transaction Reference ID

Insurance Details

Do you have any other professional indemnity insurance in your name?

Yes No

Company Name

Sum Assured

Valid Until

Payment Information

Bank Account Details

Account Name IDA Tamilnadu State Branch

Account Number 32520 20000 00202

IFSC Code IOBA0003252

Bank & Branch Indian Overseas Bank, Four Roads Branch

Declaration

I thoroughly understand that the policy shall cover incidents only based on the clauses issued by the company. I have read all the clauses and am fully aware of the range and limit of the coverage of this policy and agree to the terms and conditions.

Date

Place

Seal & Signature

Enrollment Steps

1 Transfer the premium amount
2 Fill the application form completely and sign with seal
3 Scan the duly filled application form in color
4 Mail the scanned copy to tnstateida@gmail.com
5 You'll receive confirmation within 48 working hours

Contact Information

Dr. K.P.Senthamarai Kannan
Hon. State Secretary
IDA Tamilnadu State Branch

Address:
Sree Sarojaa Multispeciality Dental Clinic,
Opp. to A.R.Line, Kumarasamypatty,
Cherry Road, Salem – 636007.

Cell: 9385319220 / 9385319221
Email: tnstateida@gmail.com
Website: www.idatamilnadu.com