Personal Accident Claim Form

Name of Insured

Phone Number

Address

Occupation

Age

Date of Accident

Time of Accident

Place of Accident

1. How did the accident happen?

2. Injuries sustained

3. Previous injury on same body part (give details)

4a. Period confined to bed

4b. Period confined to house

5. Attending Doctor’s Name & Address

6. Past medical/surgical treatment (last 3 years)

7. Witnesses to the accident (names & address)

8. Other insurance claims (if any)

I WARRANT that the above statements and particulars are correct and complete

Date

Name

Signature

Patient Name

Doctor’s Name & Address

Injuries suffered

First Consultation Date

Period of disability (total/partial)

Permanent Disability Assessment

Previous diseases or defects (if any)

Doctor’s Signature

Qualifications

Phone Number

Date