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PERSONAL ACCIDENT CLAIM FORM

CLAIM NO

NAME AGE
PRIVATE ADDRESS TEL NO
BUSINESS ADDRESS TEL NO
PROFESSION OR OCCUPATION    
POLICY NO DATE OF LAST PREMIUM
date of accident time of accident place
details of accident (and what you were doing)
precise injuries sustained (by you)
nature of contract (if printed contract enclose copy)
name of doctor address of doctor  attending to said injuries
is (s)he your doctor?
yes no
has any other medical personnel been consulted
yes no
Have you been totally unable to attend to your business or occupation?
yes no
If so, state period during which you were totally disabled:
from to
Are you still totally unable to attend to your business or occupation?
yes no

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 you be seen by an Official of the Company?
when where
Are you entitled to claim under any other Insurance?
yes no
If so, give particulars
Have you ever claimed compensation from any Accident Company?
yes no
If so, state name of Company, amount and date received
name
amount date received
Has the current premium been paid?
yes no
if yes, when was it paid and to whom?
when
to whom

NB. THESE QUESTION MUST BE FULLY ANSWERED

DECLARATION
I do hereby solemnly and sincerely declare that the foregoing and particulars are true, and that I will / have not abstain(ed) from following my usual occupation, either totally or partially, for a longer period than necessary.
do you agree
yes no

IT IS NECESSARY THAT THESE QUESTIONS BE ANSWERED BY A MEDICAL PRACTITIONER. THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM.
MEDICAL CERTIFICATE
When did you first attend upon the Claimant in consequence of the injuries sustained?
Are you still in attendance?
yes no
Are you his usual Medical Attendant?
yes no
If so, how long have you known him?
What was the cause of the Accident, so far as known to you?
What injuries were sustained?
Regions injured
Nature and extent of injuries:
Are the symptoms from which he suffers due to (a) the Accident alone:
yes no
(b)  are  they traceable to any other cause
yes no
Is he now, or was he at the time of the Accident, subject to or suffering from any illness or disease irrespective of his injuries?
yes no
if so, state the nature of same, and to what extent his recovery may be affected thereby
Are you aware of anything in his previous medical history which might have contributed, directly or indirectly, to the occurrence of the Accident, or which may be likely to retard in any way his recovery from it?
yes no
Is  he now, or has he been at any time since the date of the Accident totally disabled from attending to his business or occupation?
yes no
If so, give the dates: 
from to

TEMPORARY TOTAL DISABLEMENT occurs when, through accidental bodily injury the Claimant is directly and wholly incapacitated from engaging in, or giving attention to, his usual business or occupation.
If so disabled, please state your opinion as to the probable FUTURE duration of such disablement and probable date of his being able to resume some portion of his usual business or occupation
If he has been able to attend to a portion only of his usual business or occupation, please state since when, and also the probable date of recovery.
since date of recovery

TEMPORARY PARTIAL DISABLEMENT arises when the injury received does not wholly prevent the Assured from attending to business, or when Total Disablement ceases and he can attend to some portion of his usual business or occupation, but not the whole
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