Employer's Liability Claim

1Claim Information
2Supporting Documents

Policy Number

Branch or Agent to whom you paid your last premium

Name of Insured

Address

Telephone No

Trade or Occupation (if more than one state all)

Full Name of injured person

Address of injured person

Age of injured person

Occupation of injured person

How long has he/she been in your direct employ?

Is injured person married/single?

Place of Accident

Date of Accident

Date Reported

To whom

Was an entry made in the Accident Book at that time?

Description of work on which injured person engaged

If machinery was involved, please give details of make and type

Explain fully how accident occurred

Names and Addresses of witnesses of accident

State nature of injury ( if to limb or eye state right or left)

Date when injured person ceased work

How long do you expect him to be off work?

Has the injured person made a claim? If so, please give particulars (see note below)

Correspondence and claims. All communications and claims received by you concerning the accident are to be forwarded immediately without acknowledgement. The Corporation should also be advised of any communications received from the Factories Inspectors.

I/We declare that these particulars are true and complete. I/We understand that the information given on this form may be submitted to solicitors for use in connection with any litigation arising out of this accident.

Date of acknowledgement

Supporting Documents

Forms

Others

Country

Proposal+-

Claims

Proposal

Claims

Employer's Liability Claim

Correspondence and claims. All communications and claims received by you concerning the accident are to be forwarded immediately without acknowledgement. The Corporation should also be advised of any communications received from the Factories Inspectors.

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