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1 Personal Accident Claim Phillips House 12 Church Street Harwich Essex CO12 3DS Phone: Fax:

2 What Should I do Now? Please ask your doctor to complete the Medical Certificate at the end of the claim form. How to Complete the Form. 1. Please complete all relevant sections of the form fully and clearly in BLOCK CAPITALS. 2. If you require any advice or assistance in completing the form please contact ISU HQ or the finance officer. 3. Please remember to sign the declaration at the end of the form. 4. Please send the completed form to the address on the front page. Do keep a copy for your records. What will ISU do now? When we receive your completed claim form we will act in accordance with the terms and conditions of this policy, the ISU rules and constitution. If we require more information we will contact you. Fraud Warning The submission of a bogus or exaggerated claim, either in whole or in part, or of any false documentation or statement in support of your claim, may invalidate the whole claim. 2

3 Personal Accident Claim. Section 1. Your Details Full Name(s) Address Telephone Number Day Eve Mobile Have you smoked any cigars or cigarettes in the last 12 months? Age Height Weight NI Number Grade / Occupation Business Address Nature of Business 3

4 Personal Accident Claim. Date and Time of Accident. Section 2. Accident State Exactly what you were doing at the time. State what Injuries you have. Is there any other insurance or other policy from which you stand to benefit? Or was another party responsible for the injuries incurred? If so please give details. 4

5 Personal Accident Claim. Section 3. Hospital Benefit. Were you admitted to hospital as a result of your accident? If Yes state date and time you were admitted to hospital. If Yes state date and time of discharge. Please forward a letter from the Hospital confirming dates and times of both admittance and discharge. Section 4. Reason for claim, Please state in what way you have suffered financial hardship as a result of this injury. 5

6 Personal Accidental Claim. Section 5. General Questions. How many days have you been unable to work or engage in your usual activities as a result of this injury? Are you still unable to work or engage in your usual activities? If Yes how long do you anticipate being unable to return to work? If No when did you return to work? Name and address of attending you at present. Is he/she your usual medical attendant? If No then who is? Are you claiming any other insurance? If Yes give details. Section 6. Declaration. I declare that the above statements are true and correct to the best of my knowledge and belief. I have not withheld any information connected with this claim. I accept that if I exaggerate any part of this claim or make any false declaration or statement I shall not be entitled to any benefit in respect of this claim. Furthermore I accept that any such action on my part may render me liable to prosecution. I understand that you may seek information from other insurers to check the answers I have provided. I agree to provide the ISU with any further information or documentation as may reasonably be required. Signature of claimant, Date. Please have the medical certificate completed by your doctor. 6

7 Personal Accident Claim. 1. Name and address of Claimant. Section 7. Medical Certificate. 2. Please state the period(s) of incapacity likely to result from the accident. 3. Is the claimant totally incapacitated from attending to his/her usual occupation? If No please indicate extent of present incapacity. 4. Has the claimant been able to attend to any portion of his/her usual occupation? If Yes from what date was he/she able to do so? 5. What treatment, medication or therapy has been prescribed? 6. Do you envisage the need to refer the claimant to a specialist? If Yes to whom and when? 7. Are you are aware of anything in the claimants previous history which may be likely to delay his or her recovery? If Yes please give details. 7

8 Personal Accident Claim Section 7. (Continued) 8. When do you expect the claimant to return to work? 9. Please state: A) Nature and extent of injury sustained B) Regions injured C) Are the symptoms from which the claimant suffers due to the accident alone? If No please give details of the cause 10. To your knowledge and belief is the claimant subject to or suffering from any disease or illness, irrespective of his/her injuries? If Yes please state nature of the same and describe to what extent the recovery of the claimant may be affected. Signature of Doctor Qualifications Address Date Doctors stamp.. 8

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