Personal Accident Claim

Name of Insured

Address

Telephone No.

Policy No.

Agent/Broker

Name of Injured Person

Address of Injured Person

Occupation of Injured Person

Age of Inured Person

2. How did the accident happen? (Please State Fully)

3 (a). When did the accident occur?

3. (b). Where did the accident occur?

4. Who witnessed the occurence?

5. Nature of injuries

6. Have you been tottally and completely disabled as a result of the injuries recieved?

7 (a). When did total disablement commence?

7 (b). When did confinement to the house commence?

8 (a). Are you at the present time totally disabled?

NoYes

8 (b). Are you at the present time confined to the house?

NoYes

9 (a). When do you anticipate being able to leave the house?

9 (b). When did you resume at least part of your duties or attend to some portion of your business?

10. Name and address of the doctor who attented to you immediately after the accident?

11 (a). Who is your usual medical attendant?

11 (b). Have you consulted him in respect of your injuries?

NoYes

11 (c). When did you last consult him prior to this accident and for what purpose?

I/We hereby declare the above to be True and Correct to the best of my/our knowledge and belief.

Date of acknowledgement

Supporting Documents