"PERSONAL ACCIDENT INSURANCE CLAIM FORM - PDF"
PERSONAL ACCIDENT INSURANCE CLAIM FORM Procedures for filing a claim * This form is for the General Insurance Division only. By furnishing this form the Company makes no admission of liability. 1) Section A should be fully completed and you have to sign the Declaration and Authorisation. 2) Section B is completed and signed by the Insured Person's attending Physician. 3) Available original medical bill(s) must be submitted together with this form. Agent Code Policy No Section A: Insured Person Information 1) Name of Insured Person Date of Birth Sex 2) Mailing Address Telephone No (Office ) (Residence ) 3) Present occupation & exact duties (If more than one, state all) ( ) Name, address and business of employer 4) State fully the particulars of the accident. (a) On day of the at am/pm (a) When did it occur? (b) (b) Where did it occur? (c) (c) How did it occur? (d) (d) Which part of the body was injured? 5) (a) Give the Name and Address of the Medical Attendant who (a) attended to your injuries. (b) (b) Details of hospitalisation (Please attach Discharge Note) 6) (a) Date on which you ceased work due to your disability? (a) (b) Date on which you returned to work? (b) 7) Date on which you expect to return to work if you have not already done so? 8) If after your return to work you were not immediately able to (a) perform all your duties, indicate: (b) (a) Date of your return to work: (c) (b) Details of duties you were not immediately able to perform: (c) Date on which you were finally able to perform all your duties: 9) Are you insured with any other insurance company for Accident benefits? If so, please give particulars. Declaration & Authorisation I/WE HEREBY DECLARE AND AGREE on behalf of myself, the deceased, the claimants and other Persons referred to in this claim form ("Relevant Persons") that (1) all statements and answers to all questions whether or not written by my own hand are to the best of my knowledge and belief complete and true and; (2) any personal data of the Relevant Persons collected or held by AXA China Region Insurance Company (Bermuda) Ltd ("the Company") (whether contained in this claim form statement or otherwise), may be used in connection with matching for whatever purpose (whether or not with a view to taking any adverse action against the Relevant Persons and/or the deceased's estate) with such other personal data and/or may be used, stored, disclosed, transferred (whether within or outside Hong Kong) to such persons as the Company may consider necessary including without limitation any of its affiliated companies, reinsurers or any individuals/organisations associated with the Company to (i) process and deal with this claim recovery and underwrite and evaluate any other insurance policies and/or application for insurance (ii) provide all services related to this claim and underwrite and evaluate any other insurance policies and/or application for insurance and promote, improve and further promotion of services by the Company and its affiliated companies (iii) communicate with the Relevant Persons for any other purpose and/or comply with the laws of any applicable jurisdiction. If the Relevant Persons fail to provide any information requested in this claim form, it may result in the Company's inability to process and deal with this claim. I/WE HEREBY AUTHORISE on behalf of the deceased and the claimant any employer, registered medical practitioner, herbalist, bonesetter, hospital, clinic, insurance company, bank, government institution, or other organisation, institution or person that has any records or knowledge of the deceased and/or the claimant and who has attended to the deceased and/or the claimant to disclose such information to the Company. This authorisation shall bind my successors and assignees and remains valid notwithstanding death or incapacity. A photocopy of this authorisation shall be as valid as the original. I/WE DECLARE AND AGREE that I/we have the full authority from and consent of the Relevant Persons to make the above declarations, agreements and authorisations. The Relevant Persons have the right under the Personal Data (Privacy) Ordinance to request, access to and correct any of the personal data held by the Company concerning the Relevant Persons. Any request may be made in writing and addressed to the head of the General Insurance Claims Department at 36/F Tower One Times Square 1 Matheson Street Causeway Bay Hong Kong. Signature of Insured Person HKID No: : Signature of Policyholder/Policy Owner HKID No: Name in BLOCK Letters Date Witness HKID No: Date Please make sure that the above signatures of the Policyholder/Policy Owner/Insured Person are consistent with that in the Policy Application In the event of the Insured Person being unable to sign the form, it should be filled and signed by the Policyholder/Policy Owner or a close relative or other responsible person in charge of the Insured Person during his/her disability. GI111CF-0701 Office: * 36/F Tower One Times Square 1 Matheson Street Causeway Bay Hong Kong General Insurance Division Tel (852) 2828 8330 Fax (852) 2511 9851 (852) 2828 8330 (852) 2511 9851 Section B: Certificate of the Medical Attendant No Claim can be processed unless accompanied by a Medical Certificate and the form below is completed by a qualified and registered medical practitioner and furnished at the expense of the Policyholder/Policy Owner/Insured Person. Patient's Name HKID Card No Age 1) Date of Accident: 1) 2) Cause of injury: 2) 3) Part of body injured: 3) 4) Nature and extent of injuries: (Describe complications, if any) 4) 5) Is condition due to pregnancy? 5) 6) Date Patient first consulted you for this condition: 6) 7) State whether there was evidence of a visible bruise 7) or wound at the first consultation. 8) Treatment given (eg, suturing, physiotherapy, type of 8) dressing etc) Date: Time: Treatment: 9) Did injury require: (If yes, please give details) No Yes a) Hospitalisation? ❏ ❏ Date admitted ❏ ❏ Date discharged b) X-rays? c) Special diagnostic procedures? d) Surgery? 10) Bearing in mind the Patient's occupation as stated overleaf, ❏ ❏ a) Total and absolutely disabled (unable to work): do you feel that the injuries would have prevented him/her from to . from performing his/her duties? If yes, please give details. b) Partially disabled: from to . 11) Give details of any circumstances, such as physical 11) impairment, medical history or intoxication which may have contributed to the accident and/or Iengthened the period of disability. 12) Names and addresses of other doctors who have treated 12) the Patient for the same injury: Name: Office Address: Office Tel No: Date: I HEREBY CERTIFY that I have personally examined/treated the Patient for the above injuries and that the facts as given above present my opinion of his/her condition. I declare and agree to make the declarations on Section A of this claim form. Signed: Name of Physician: Date: Office Address: Qualifications: Office Tel No: For identity purposes, the Patient must sign below in the presence of the Physician: Date: Signed: