Independent Medical Evaluators

 



  • Please state your fees received for your IME services ONLY in respect of the following years:

    TOTAL REVENUE:




  • Please give details of the 5 largest contracts you have carried out in the past 3 years:

    Client 1.


  • Client 2


  • Client 3


  • Client 4


  • Client 5


  • Please confirm the following:


  • CLAIMS INFORMATION




  • 1. After full inquiry, you are not aware of any circumstances, complaints, claims, loss, or penalties/fines levied against you in the last five years, in relation to the risks that this application relates to.
    2. After full enquiry, you are not aware of any current or previous problems or errors in your work that may give rise to a liability claim against you, in relation to the risks that this application relates to.


    DECLARATION

    I declare that after proper inquiry the statements and particulars given above are true and that I have not miss-stated or suppressed any material fact.

    I agree that this application form, together with any other material information supplied by me shall form the basis of any contract of insurance affected thereon.

    I undertake to inform underwriters of any material alteration to these facts occurring before completion of the contract.
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