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Personal Accident Claim Form: Issuance of This Form Does Not Imply Acceptance of The Liability

This personal accident claim form collects information about an accident in order to process an insurance claim. It requests details about the claimant, policy, accident, injuries, doctors, and a medical certificate to be completed by the treating physician. It informs that submitting the completed form within 180 days of the accident does not imply acceptance of liability and that providing inaccurate information can result in forfeiture of rights under the policy.

Uploaded by

Ali Alaamiry
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© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
66 views

Personal Accident Claim Form: Issuance of This Form Does Not Imply Acceptance of The Liability

This personal accident claim form collects information about an accident in order to process an insurance claim. It requests details about the claimant, policy, accident, injuries, doctors, and a medical certificate to be completed by the treating physician. It informs that submitting the completed form within 180 days of the accident does not imply acceptance of liability and that providing inaccurate information can result in forfeiture of rights under the policy.

Uploaded by

Ali Alaamiry
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Personal Accident Claim Form

CLAIM NUMBER:

Issuance of this form does not imply acceptance of the liability

Please submit the complete filled form within 180 days of the accident

POLICY NUMBER: ______________________

DATE OF REGISTRATION: _____ /_____ /_____

NAME OF THE CLAIMANT: _________________________

CLAIMANT ID: __________________________

ADDRESS:
__________________________________________________________________________________________
__________________________________________________________________________________________

PHONE NUMBER: ________________________

OCCUPATION: ___________________________

DETAILS OF THE ACCIDENT:


__________________________________________________________________________________________

NAME OF PATIENT IN ACCIDENT: _____________________________

RELATION WITH THE INSURED: ________________________________________________________________

(ID / PASSPORT) NUMBER: ____________________

DATE OF THE ACCIDENT: _____________________

PLACE OF THE ACCIDENT: ______________________

NAMES AND ADDRESSES OF THE WITNESSES:


__________________________________________________________________________________________
__________________________________________________________________________________________

PARTICULARS IN THE ACCIDENT:


__________________________________________________________________________________________
__________________________________________________________________________________________

NATURE OF THE INJURY RECEIVED (WHICH LIMB/S, RIGHT OR LEFT):


__________________________________________________________________________________________
__________________________________________________________________________________________

NATURE OF DISABLEMENT (TEMPORARY OR PERMANENT):


__________________________________________________________________________________________
__________________________________________________________________________________________

NAME AND ADDRESS OF THE TREATING DOCTOR:


__________________________________________________________________________________________
__________________________________________________________________________________________

PERSONAL ACCIDENT CLAIM FORM 1


Personal Accident Claim Form

WHERE AND WHEN CAN A MEDICAL OFFCIR VISIT YOU (if necessary):
__________________________________________________________________________________________
__________________________________________________________________________________________

I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge. In the event above information
or any part thereof is found Incorrect, I agree that all right under the policy will be forfeited. I agree to provide additional Information to the
Company if required. I will indemnify and hold harmless the Company due to any loss arising out of misstatement in this form and am willing
if required, to make a statutory Declaration before a Justice of the Peace of the truth of the whole of the foregoing statement or any other
statement I may make in connection with this claim.

Name of the witness: _____________________________

Signature: ________________________

Name of the claimed person: _______________________

Date: _____ /_____ /_____

PERSONAL ACCIDENT CLAIM FORM 2


Personal Accident Claim Form

Medical Certificate to be filled by the treating doctor

1. Name of the claimant


2. Age
3. Nature and cause of the accident
4. Which limb affected?
5. Please confirm if the injury seems to be related to the accident?
6. When was the first visit of the patient?
7. Has the claimant been totally prevented from attending to any portion of his business? If so how
long?
8. Is the claimant suffering from any disease or illness apart from his injury, if so please mention them?
9. Current condition of the patient
10. Do you consider this case as partial disability or total disability*?

Having personally examined the above claimant, I certify the above statements are correct and that the
injured person /claimant is necessary disabled by the accident referred to.

Signature: _______________________________ Stamp: _________________________________

Name: __________________________________ Specialty: _______________________________

Address: ________________________________

*Permanent total disability means that patient is completely disabled as a result of injury or work-related illness and can no
longer work in the capacity for which you were trained

PERSONAL ACCIDENT CLAIM FORM 3


Personal Accident Claim Form

No. Accidental Death / Document type Yes/ No

1. Duly filled, signed and stamped claim form

2. Original copy of Death certificate

3. Original copy of post mortem examination report( Forensic )

4. National ID / Passport

5. Police report

6. In case of Death happened inside the hospital please support us with copy of the
medical file

No. Permanent Total Disability /Documents type Yes/ No

1. Duly filled, signed and stamped claim form

2. Complete treatment record like discharge summary , consultation papers with


supporting investigations like x-rays , MRI, CT scan …etc.

3. Police report

4. National ID / Passport

Please note all the above list is only indicative, insured \ claimant may have to submit additional information
if required

PERSONAL ACCIDENT CLAIM FORM 4

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