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?

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?

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?

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:

Date: