MEMBERSHIP FORM FOR NURSES
Name of the Attendant-
Name of the Nursing Home/Hospital –
Address of the Nursing Home/Hospital -
PIN-
City-
State-
E-mail Id-
Contact Details-
Whether registered with Delhi Nursing Council-
Year of Registration-
Existing policy or membership with any insurance company (Yes/ No) If yes, name of Insurance Company-
Sum insured-
Name of Policy-
Any claim experience-
Any pendency or litigation relating to medical or personal-
If yes, please share the brief description about the nature and stage of litigation (this detail is required if you wish to have our membership for non-medico legal cases as well)-
If you wish to take membership for any colleague doctor/ please share their name with educational qualification-
If you get the membership for any other qualified Staff/Lab Technician. If yes, please share the details-
Any other information-
PAYMENT DETAILS-
DATE
DRAWN ON
CHEQUE NO./DD/NO
AMOUNT
NOTES
As per Services of Medins Legal LLP I hereby voluntarily declare to be a member of Medins Legal LLP for which I deposit Rs. for year/s and I am quoting my details above.