Personal Accident Claim Form

Step 1 of 2

PLEASE STATE AS FULLY AND AS ACCURATELY AS POSSIBLE THE INFORMATION ASKED FOR BELOW. ACCEPTANCE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

INSURED

N.B. BOTH CLAIM FORM AND DOCTOR’S CERTIFICATE TO BE COMPLETED AND RETURNED IMMEDIATELY

Name(Required)

Address(Required)

Home Telephone No.(Required)

Busines Telephone No.(Required)

*SHOULD THE COMPANY BE LIABLE TO SETTLE THIS CLAIM PLEASE TICK THE APPLICABLE

DEPOSIT CHEQUE INTO:

BANK(Required)

ACCOUNT NUMBER(Required)

BRANCH(Required)

SEND CHEQUE VIA MY BROKERS

The Accident:

Date(Required)

Time(Required)

Place(Required)

Description of Accident(Required)

Names & Addresses of Witnesses(Required)

Particulars of injuries(Required)

Name and address of doctor in attendance(Required)

How long have you been totally or partially disabled from work as a result of your injuries?

Totally From(Required)

Totally To(Required)

Partially From(Required)

Partially To(Required)

How long have you been confined to Hospital?

From(Required)

To(Required)

How long have you been confined to House?

From(Required)

To(Required)

When do you expect to be fit to resume your occupation?(Required)

Are you claiming under any other insurance?

Yes

Please give particulars(Required)

If the Insured is unable to attend to this form, it should be completed on his behalf.

Date(Required)

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