Account No.
Policy No :
Branch or Agency :
Claim No :
This form is issued without admission of Liability, and must be completed and returned within seven days after its receipt. No Claim can be admitted unless the MEDICAL CERTIFICATE OVERLEAF be furnished at the expense of the Claimant.
1. Name in Full :
Present Age :
Height :
Weight :
Residence :
Telepone No :
Business Address :
Present Address or Occupation (If more than one. state all.) :
2. (a) When did accident occur? State day, date, and hour.
(b) Where did it occur?
(c) Give full particulars of the cause and the injuries sustained
3. Give names and address of any witnesses of the accident
4. (a) Give name and address of Doctor who attended you
(b) Name and address of your ordinary Medical attendant
5. (a) State where and when a Medical or other Officer of the Company can visit you, if necessary
6. (a) State the period during which you have been totally disabled from attending to your business as the sole and direct result of the accident
(b) Are you still totally disabled? If not, from what date were you able to attend to some part of your business?
7. (a) Have you previously claimed or received compensation under an Accident and/or Sickness Policy? If so, please give particulars
8. (a) Are you insured elsewhere?
(b) If so, give the name of each Company or Insurer, and amount you are entitled to claim
I HEREBY DECLARE that I have received the injuries above described, and warrant the truth of the foregoing particulars in every respect, and I agree that if I have made, or if I shall make, any false or untrue statement, suppression or concealment my right to compensation shall be absolutely forfeited.
Date : Full name of insured :
Name of patient
Profession or Occupation
Are you the Patient's usual Doctor?
Period known to you
Cause of incapacity
Date Patient first seen
State nature and extent of injuries
Disablement From To Prognosis (Please indicate probable duration of disablement)
Confined to house
Unable to give attention to any occupation
Able to give some attention to this occupation
If Patient has now fully recovered, date of recovery.
Dates and details of injuries from which he has previously suffered
I hereby certify having personally examined the above-mentioned Patient, that in my opinion the disability arises solely as a result of the accident described and that there are no other circumstances tending to produce either total or partial disability except
Full Name : Qualifications :
Address     : Date                 :