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Personal Accident Claim Form


Please complete all questions as fully as possible
Policy Number
Insured’s Name Email
Telephone no Address
  Description of business
Name of injured person (in full) Age
Address (in full) Occupation
Please state amount of salary or wages paid to injured person for twelve months prior to the accident
Accident: Date Time
Place State how the accident occurred
Did the accident happen while the injured person was engaged in your business? Please describe injuries
State the name and address of the doctor attending the injured person
Date injured person ceased work When do you expect him/her to resume work? .