GROUP PERSONAL/PERSONAL ACCIDENT CLAIM FORM
This form should be completed and returned within seven (7) days. It is necessary that the questions overleaf be answered by a medical practitioner. Please, answer all questions fully and return forms without delay
Policy No:
Claim No:
Insured:
Email:
Contact Address:
State:
GENERAL QUESTIONS:
State when and where the Accident took place:
Place:
Date:
Time:
State how it happened and what you were doing at the time: The fullest particulars should be given
State, as precisely as you can, what injuries you have sustained:
Give name and address of the Doctor attending to you or said injuries:
Had any other Medical professional been consulted? [select* medical "yes" "no]
Have you been totally unable to attend to your business occupation?
If so, state period during which you were totally disabled:
From
To:
Are you still totally unable to attend to your business or occupation? yesno
If not, on what date were you able to attend to;
A portion of your occupation?
The whole of your usual occupation
When and where can medical professionals or other officers visit the company?
Are you entitled If so, give particulars:?
Have you ever claimed accident compensation from any Company? yesno
If so, state name of Company, Amount and Date received:
DECLARATION
I do hereby solemnly and sincerely declare that the foregoing statements and particulars are true, and that I will not abstain from and have not abstained from the following my usual occupation, either totally or partially, for period than necessary
Signature of Claimant:
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