Claim Form Personal Accident Insurance by suchenfz


									                                   CLAIM FORM
                           PERSONAL ACCIDENT INSURANCE

1)       Name and Address of the                  :

2)       Business/Occupation                      :

3)       Policy Number                            :

4)       Age and Occupation of the Injured        :

5)       Date, time and location of accident      :

6)       Description of Accident                  :

7)       Cause of Accident                        :

8)       Nature and Extent of Injury              :

9)       Name and address of the Hospital         :
         where injured was treated
10)      Name and address of Doctor who
         attended injured
11)      Details of other existing insurance

11)      Amount Claimed                           :

      I/We hereby declare that the above information given is full and true to the best of my
      knowledge and belief.

         Date :                            Signature of the Contributor
                                                        Name and Signature of the Witness

      In case of any requirements or clarification, kindly contact our FGA Department
      Tel: 2477200 Ext. 189-190-191-192, Administration Department Fax: 2477100 ,
      Technical Departments Fax: 2476174 , E-mail Address:

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