Personal Accident Insurance - Insured/Claimant's Statement
SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY
Claim No.
(for official use only)
Policy No.
1. a) Name of Claimant(in full) if more than one state names of all.  
  b) Full Postal Address.  
  c) Relationship of Claimant with Insured person.  
2.   State nature of title under which Claimant is claiming amount.  
Description of the Insured Person who involved in Accident
3. a) Name (in full)  
  b) Last full Postal Address  
  c) Occupation  
  d) Age at time of accident  
4. a) When did accident happen? (Give date and exact time)  
  b) Where did accident happen?  
  c) Give full description of accident, its cause and injuries sustained.  
5.   On what date did claimant receive information in regard to accident and from whom?  
6.   Give names and addresses of two Persons who witnessed accident.  
7. a) Was injured person free form infirmity at time of accident? if not, give description.  
  b) Was injured person under influence of drugs or drink at time of accident?  
  c) Is claimant satisfied that injury was directly due to accident?  
  d) Give names and address of:    
 
1.
 Hospital, Clinic or Nursing Home where injured person was treated after accident.  
 
2.
 Physician/ Surgeon who attended injured person after accident.  
 
3.
 His regular physician if any.  
8.   Did injured person have any other accident Insurance on his life? If so, state name of Insurer/s and amount/s claimed.



  
9.  
Incase of Permanent Disablement give full description of injury as result of accident and Medical attendant's Certificate of total/ irrecoverable loss of sight or actual loss by physical separation of limb.
  
I/ We hereby affirm and declare that answers to all above questions are full and true in every respect.
 
Place: Date:
Witnesses:
Name:  
Address: