Birdview Insurance
Personal Accident Claim Form
Insured Details
Name of Insured
*
Name of Insured *
Phone Number
*
Phone Number *
Address
*
Address *
Occupation
*
Occupation *
Age
*
Age *
Date of Accident
*
Date of Accident *
Time of Accident
*
Time of Accident *
Place of Accident
*
Place of Accident *
Accident Details
1. How did the accident happen?
*
1. How did the accident happen? *
2. Injuries sustained
*
2. Injuries sustained *
3. Previous injury on same body part (give details)
*
3. Previous injury on same body part (give details) *
4a. Period confined to bed
*
4a. Period confined to bed *
4b. Period confined to house
*
4b. Period confined to house *
5. Attending Doctor’s Name & Address
*
5. Attending Doctor’s Name & Address *
6. Past medical/surgical treatment (last 3 years)
*
6. Past medical/surgical treatment (last 3 years) *
7. Witnesses to the accident (names & address)
*
7. Witnesses to the accident (names & address) *
8. Other insurance claims (if any)
*
8. Other insurance claims (if any) *
Declaration
I WARRANT that the above statements and particulars are correct and complete
Date
*
Date *
Name
*
Name *
Signature
*
Signature *
Medical Certificate (To be completed by Doctor)
Patient Name
*
Patient Name *
Doctor’s Name & Address
*
Doctor’s Name & Address *
Injuries suffered
*
Injuries suffered *
First Consultation Date
*
First Consultation Date *
Period of disability (total/partial)
*
Period of disability (total/partial) *
Permanent Disability Assessment
*
Permanent Disability Assessment *
Previous diseases or defects (if any)
*
Previous diseases or defects (if any) *
Doctor’s Signature
*
Doctor’s Signature *
Qualifications
*
Qualifications *
Phone Number
*
Phone Number *
Date
*
Date *
Scale of Permanent Disablement Benefits
Disability
% Payable
Permanent Total Disability
100%
Total Paralysis
100%
Loss of use of two limbs
100%
Loss of use of one limb
50%
Loss of sight in both eyes
100%
Loss of remaining eye
100%
Loss of sight in one eye
50%
Loss of speech & hearing
100%
Loss of speech only
50%
Loss of hearing both ears
75%
Loss of hearing one ear
40%
Loss of use of both hands
100%
Loss of use of one hand
50%
Loss of one finger
10%
Loss of both feet
100%
Loss of one foot
50%
Loss of one toe
10%
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