Personal Accident Insurance (Death) - Insured/ Claimant's Statement
Click to view procedures for lodging claim
SUBMISSION OF THIS FORM DOES NOT BIND COMPANY FOR LIABILITY
Policy No Claim No
(for official use only)
1. a) Name of Claimant (in full) if more than one state names of all.
  b) Full Postal Address
  c) Relationship of Claimant with deceased.
2. State nature of title under which Claimant is claiming amount.
Description of the Insured Person who died in Accident
3. a) Name (in full)
  b) Last full Postal Address
  c) Last occupation
  d) Age at time of accident Years
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 causing death.
  d) State date, time and place of death.
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 deceased free from infirmity at time of accident ? if not, give description
  b) Was deceased under influence of drugs or drink at time of accident ?
  c) Is claimant satisfied that death was directly due to accident?
  d) Give names and address of  
    Hospital, Clinic or Nursing Home
where deceased was treated after accident
    Physician/Surgeon who attended on deceased after accident
    His regular physician if any
8. Did deceased have any other accident Insurance on his life ? if so, state name of Insurer/s and amount/s claimed
I/We hereby affirm and declare that answers to all above questions are full and true in every respect.
Place
Date
Witness  
Name
Address