Personal Accident Claims

New Personal Accident Insurance Claim Form

A. Policy Holder Details

Name of insured

Age

Email Address

A. Insured

Address

Policy No

Date of payment of last premium

B. Other Insured

Name of Insured Person (if other than policy holder)

Age

Address

Present Occupation

C. Accident

Place of Accident

Date of Accident

How did it happen?

What were you doing at the time?

Nature of injuries

Details, of inability to follow occupation:

Disabled totally from

Disabled totally to

Disabled partially from

Disabled partially to

D. General (to be completed for both Accident Claims)

Are you insured against accident with any other Company? If so, give name and amount, of benefit

Prior to the above accident have you suffered from this or any other injury? If so, give particulars with approximate date and periods of incapacity

Do you suffer from any other Physical Defect or Infinity? If so, give details

Additional Information Required Under Group Policies Where The Benefit Is Related To Salary Or Wages (To Be Completed By Employer)

Annual salary or weekly wages at time of accident

Statement Of Wages Paid To

Please state reasons for any absence from work within the last 52 weeks or shorter period of prior to the accident (i.e. Sickness, Holiday, and others), when no wages or only part wages were paid in respect of any week(s).

*Kindly attach a PDF, word or excel detailing your wages for 52 weeks

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New Personal Accident Insurance Claim Form

A. Policy Holder Details

A. Insured

B. Other Insured

C. Accident

D. General (to be completed for both Accident Claims)

Additional Information Required Under Group Policies Where The Benefit Is Related To Salary Or Wages (To Be Completed By Employer)

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