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







    GENERAL QUESTIONS:

    State when and where the Accident took place:









    If so, state period during which you were totally disabled:




    If not, on what date
    were you able to attend to;







    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