Claim Form : 'Travel Insurance' - TRAVELeasy
Policy No.
Claim No. ………………………...
ACCIDENT CLAIM FORM
(This form must be completed and forwarded to the Company within three days and a Medical Report stating diagnosis must also be forwarded soonest).
1) Employer’s Name & Address ……………………………………………………………….……..
…………………………………………………………………………………….……………….
2) Business …………………………………………………………………………………………..
3) Name of Injured …………………………………………………………………………….…….
4) Age ………… Single or Married ……………………… Occupation …………………….…….
5) Daily, weekly or monthly wage or salary (state amount) ………………………………………….
6) When did he enter your service ……………………………………………………………………
7) Was he in your direct employment or in that of sub-contractor –
If the latter, please name and address of sub-contractor ……………………...………………….…
8) Place of accident (site) …………………………………………………………………………….
9) a. Name of Police Station or area where the accident took place ………………………….……..
b. Date of Accident ……………….. ……………………………………………………………….
10) What duty was he performing at the time of accident ? ………………………………….………..
11) Cause of accident (in detail) ………………………………………………………….……………
……………………………………………………………………………………………………...
12) Nature and extent of injury ……………………………………………………………….………..
13) Probable duration of disablement ………………………………………………………………….
14) Name of witnesses and their addresses ……………………………………………….….….…….
……………………………………………………………………………………………………...
15) Was accident due to another person’s negligence?
If so, give particulars ………………………………………………………………………………
16) If taken to hospital, state which and whether
in-patient or out-patient …………………………………………………………………………….
17) Have you any other insurance, indemnity covering accidents
to your employees? If so, give particulars ………………………………………………………...
18) Other remarks ……………………………………………………………………………….……..
Date ………………………….. ……………………………….. Employer’s Signature/Stamp
OIC Direct – Toll free No. 8004746
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