WORK INJURY BENEFIT CLAIM FORM
|
|
- Christal Short
- 8 years ago
- Views:
Transcription
1 WORK INJURY BENEFIT CLAIM FORM Important information please read carefully i. This report is to be completed by the employer in case of injury to or death of a workman and returned back along with the following documents: Duly completed DOSH I & II forms Duly completed WIBA 4 form Witnesses statement (if any), Supervisor s statement and Claimant s statement I.D. copy of the claimant Any other supporting documents ii. If any detail of information is not available immediately, please do not delay dispatch of this report. Such particulars should be sent later. iii. Subject to the provisions of the WIBA an employer is required to report an accident to the Director of Occupational Health and Safety either verbally or in writing within 24 hours in case of fatal injuries, and within seven days for non-injuries. This includes any accident reported by an employee to an employer and the employer alleges that the same arose out of and in the course of employment irrespective of the opinion of the employer. iv. Ensure that all the sections of this claim form are fully completed. v. Please note that this claim form must be completed in English. vi. The Golden Rule to follow in the event of an occurrence which may give rise to a claim is : NOTIFY US IMMEDIATELY AND ACT AS IF YOU ARE UNINSURED AND ON THIS BASIS MINIMISE THE LOSS DO NOT ADMIT LIABILITY 1. The Employer a) b) Address c) Industry or business Number Postal Code Town d) Policy No. Commencement date Expiry e) Are you registered with the Director of Occupational Health and Safety Yes No If yes, what is your Registration No. 2 The workman involved in employment injury a) Full name b) Physical address c) Permanent address d) Sex Male Female e) I.D. No. f) Activity undertaken at time of accident g) Workman s job description h) Status of employment Permanent Temporary Casual Under a contract If under contract, the name of the contractor (Kindly attach a copy of the contract)
2 Work Injury Benefit Claim Form j) When did the injured person enter your service k) Monthly or daily earnings at the time of the accident l) Has the workman filed a suit Yes No k) Has the workman filed any suit against you previously Yes No If yes, give details of suit k) Is the injured person still in employment Yes No If not, state date he/she ceased employment l) Was the injured workman suffering at the time of accident from ill health or bodily defect or infirmity of any description Yes No If yes, give details of suit 3. The accident a) Time Place b) At what time and from whom did you receive notification about the incident c) Has the incident been reported to the Director of Occupational Health and Safety Yes No If yes, date reported how (Submit documentary evidence with this form) d) Cause of accident e) Was the workman recorded on duty on the day of the accident Yes No f) What duty was the workman assigned at the time of the injury g) If injury was caused by machine: - State of machine and parts causing the injury - Was it fenced or guarded Yes No - Was the machine being cleaned Yes No - What was the general nature of the work going on - Was it in motion at the time of injury Yes No - Who was responsible for switching it ON/OFF - Who switched it on - His/her address - His permanent home address if different above - State exactly what the injured person was doing at the time of injury h) If injury not caused by machine(e.g. fire, free fall, carrying heavy objects, e.t.c) name the cause and give a brief description on how the workman got injured i) If motor vehicle is involved, indicate its registration number, policy number and name & address of the insurance company
3 4. The injury a) Nature of injury: Fatal Grievous Soft tissue Medical expenses only b) If fatal, give names of all dependants of the deceased workman if known c) Have the dependants informed the Director of Occupational Health and Safety Yes No If so, when and how d) Is the complaint an occupational disease Yes No If yes e) Was the claimant medically examined before commencing employment Yes No f) State to what extent the injured person is disabled and whether absolutely prevented from following his employment g) State whether the injuries are likely to cause any PERMANENT disablement h) the hospital/dispensary/private clinic where he has been treated following the accident i) Whether admitted Yes No If so, of admission of discharge j) Attendance as out-patient prior to and/or subsequent to hospitalization Yes No From To Was there a doctor s medical report Yes No (if yes, please forward copy) k) Amount expended on treatment l) Who paid for it m) Was the injury recorded on an occurrence book / injury register Yes No (If yes, please attach copy) yes, please attach copy) o) Has he/she resumed work Yes No When 5. OBSERVANCE OF INSTRUCTIONS a) Were there standing instructions/notices on how to do the assigned work Yes No b) Was the workman guilty of any misconduct or disobedience to such instructions or other orders or rules Yes No
4 Work Injury Benefit Claim Form If so, please give details c) Was the injured person under the influence of drugs or drinks at the time of accident Yes No d) Was the injured workman was provided with protective clothing/guards at the time of accident? E.g. gloves, gum boots, helmets, goggles, overalls etc Yes No If yes, state the items provided and was the workman utilizing the gear at the time of injury Yes No If not, why of supply Did the workman sign for the gear Yes No (If yes please attach a copy of the signed register) e) Was the workman found without protective gear at the time of accident Yes No If no, give reasons why f) Has his immediate supervisor brought to the attention of the insured workman the necessity of wearing protective clothing/guards when the former saw the latter without these guards at the time of commencement of his work but before the occurrence on the date of accident Yes No g) State through whose negligence this injury occurred 6. State the names, addresses (permanent and home) of the person(s) who witnessed this accident a) b) c) 7. Brief statement(s) of the above named person(s) who witnessed the accident when it occurred a b) c) (The above are factual to the best of my/our knowledge, information and belief)
5 The below part must be completed of employer Please stamp here using the signature of the employer or the company s authorized stamp STATEMENT OF WAGES The object of this statement is to ascertain the injured person s average monthly earning. Please therefore observe the following instructions carefully. Failure to do so will entail unnecessary correspondence and cause undue delay in the settlement of the claim. 1. If the injured person has been in Employer s service during a continuous period of more than one month immediately preceding the accident, the wages that have been paid or fallen due for payment, to him in each month of such period (not exceeding 12 preceding months in all) must be entered in this statement. 2. If the injured person has been in employer s service for less than one month,there must be entered in the statement the wages paid to another workmen employed on the same kind of work by the employer during the 12 months preceding the accident. MONTH WAGES BONUS VALUE OF FREE QUATRERS AND ALLOWANCES Total Total including Allowance a) Were the above stated wages paid, or fallen due to for payment to the injured person? Yes No If not, state to whom b) Was the injured person absent from work at any time, during the above stated period, for 114 or more consecutive days If so, give the following particulars; Absent for days from to Yes No RESOLUTION INSURANCE COMPANY LIMITED: Parkfield Place, Muthangari Drive, Off Waiyaki Way, Westlands P. O. Box , Nairobi, Kenya Tel: Mobile: , info@resolution.co.ke Website: RI/EB/FM/10 Rev.1 My Health, My Life, My Resolution
CLAIM FORM - WORK INJURY COMPENSATION INSURANCE. Section 1 - Particulars of Insured. Section 2 Particluars of Injured Worker
CLAIM FORM - WORK INJURY COMPENSATION INSURANCE Agency: Policy No.: Please note: 1. The acceptance of this form is NOT an admission of liability on the part of the Company. 2. All original bills, certificates,
More informationThe issue and acceptance of this form does NOT constitute an admission of liability by ACE or waiver of its rights. Email Name of Agent/Broker
WORK INJURY COMPENSATION Claim Form IMPORTANT INFORMATION 1) Insured is requested to state, as fully and accurately as possible, the information asked for below. *SG011* *SG011* 2) If any detail or information
More informationAccident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections
More informationWORKERS COMPENSATION EMPLOYER S REPORT
WORKERS COMPENSATION EMPLOYER S REPORT You must lodge this form with Allianz within three working days of being notified of an injured person s claim. 1 Employer Details Legal Entity / If Claimant has
More informationEMPLOYERS LIABILITY CLAIM FORM
EMPLOYERS LIABILITY CLAIM FORM Insured Insured Policy Number Postcode Type of Business VAT registered? Yes No Annual Turnover Non-clerical wage roll Contact Please provide details of the person we should
More informationEmployer s Liability. Accident report form. Policyholder details. Injured employee. Please return this form to:
Employer s Liability Accident report form Please return this form to: Please: Read this form fully before filling it in and where possible answer all questions in CAPITALS. Do not take any action in connection
More informationAccident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.
More informationPostal Code ( ) Citizenship: No. of Working days per week: 5 days 51/2 days 6 days Others, please specify
CLAIM FORM - WORK INJURY COMPENSATION INSURANCE Agency: Policy No.: EQ I nsurance C ompany L imited 5 Please Maxwell note: R oad, # 17-00 Tower Block Tel: 1. (65) You 6223 do 9433 not. Fax: need (65) to
More informationEmployee Benefits Product Guide
Employee Benefits Product Guide Resolution Insurance entered the Kenyan market in 2002 (as Resolution Health East Africa), the first company to be registered as a Medical Insurance Provider (MIP). We were
More informationthird party claim form RAF 1
1 personal details of claimant: Title Surname Postal address / Passport number te: A certified legible copy of your identity document must be attached to this claim form Home telephone number Work telephone
More informationAccident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.
More information1 Please ensure that the club Secretary/Treasurer completes the Official Report section of the claim form.
Playeraccident claimform Our Head Office and registered address is: Sportscover Europe Ltd 3 rd Floor, PO Box HQ420, St Helen s, 1 Undershaft, London, EC3P 3DQ Registered in England and Wales. 3726678
More informationPostal Code ( ) Email: Name of Insurer(s):
www.libertyinsurance.com.sg Document(s) for submission of claims to Liberty Insurance Pte Ltd No. Document Required Attached 1 Claim Form (Did accident arise out of and in the course of employment?) 2
More informationGROUP TOTAL & PERMANENT DISABILITY CLAIM FORM
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM A Member of the OCBC Group CLAIM SUBMISSION PROCEDURES Please read carefully before you complete the attached Claim Form. 1. 2. The Great Eastern Life Assurance
More informationCLAIM APPLICATION FORM FOR WORKMEN'S COMPENSATION INSURANCE
CLAIM APPLICATION FORM FOR WORKMEN'S COMPENSATION INSURANCE NOTE: In the event of any occurrence which may give rise to a claim under the Policy for Workmen's Compensation Insurance, the Insured shall,
More informationEmployers Liability Claim Form
Claims Reference No. (if known) Employers Liability Claim Form 1. You the Policyholder of Insured Postcode Contact Number Policy Number Business Date Premium Paid Are you a Registered Trade for VAT purposes?
More informationCLAIM FORM - EQ TRAVEL. Section 1 - Particulars of Insured. Section 2 - Details of Incident/Loss/Illness (must be completed)
CLAIM FORM - EQ TRAVEL Agency: Policy No.: Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of
More informationNT WORKERS COMPENSATION CLAIM FORM
Information for Workers Guidance to PART 1 of the Claim Form Notify your employer of your injury, verbally or in writing, as soon as practicable. Fully complete PART 1 (questions 1 to 8) of the following
More informationPROPOSAL FORM. Bajaj Allianz General Insurance Company Limited WORKMEN'S COMPENSATION INSURANCE P - 2801 -
Bajaj Allianz General Insurance Company Limited P - 2801 - PROPOSAL FORM WORKMEN'S COMPENSATION INSURANCE THE INDIAN WORKMEN'S COMPENSATION ACT 1923. The Act provides for the payment of compensation by
More informationNotice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Non-Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident
More informationWORKERS' COMPENSATION CLAIMANT INFORMATION PACKET
WORKERS' COMPENSATION CLAIMANT INFORMATION PACKET Instructions Statement of Rights Prescription ID and Pharmacy Information The New York State Insurance Fund TLC EMERGENCY MEDICAL SERVICES Inc. TLC MEDICAL
More informationNotice of Accident Claim Form
Insurer's Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) tice of Accident Claim Form (n-fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
More informationPhillips House 12 Church Street Harwich Essex CO12 3DS Phone: 01255 553039 Fax: 01255 240560 Email: hq@theisu.co.uk
Personal Accident Claim Phillips House 12 Church Street Harwich Essex CO12 3DS Phone: 01255 553039 Fax: 01255 240560 Email: hq@theisu.co.uk 1 What Should I do Now? Please ask your doctor to complete the
More informationPart 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.
Form Workers compensation claim form Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Notify your employer of your injury or disease
More informationINDIVIDUAL PERSONAL ACCIDENT INSURANCE POLICY Claim Form
SBI General Insurance Company Limited IRDA Reg. No. 144 dated 15/12/2009 CIN: U66000MH2009PLC190546 INDIVIDUAL PERSONAL ACCIDENT INSURANCE POLICY Claim Form Call (Toll Free) 1800 22 1111 1800 102 1111
More informationCLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle
Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim
More informationWorkers Compensation claim form
Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to
More informationGOGANS SPORTS PERSONAL ACCIDENT INSURANCE SCHEME
GOGANS SPORTS PERSONAL ACCIDENT INSURANCE SCHEME SECTION A CLAIMANT & CLUB DETAILS DATE OF INJURY NAME OF CLAIMANT NAME OF CLUB FULL ADDRESS OF CLAIMANT FULL ADDRESS OF CLUB DATE OF BIRTH TEAM GRADE MOBILE
More informationAIG no longer issues cheques. To confirm transfer of funds, an auto email will be sent to your broker or direct Email: Broker/Payee
Personal Accident or Sickness Scheme (Individual or Group) Claim Form Please print out for signatures and post original to your broker if applicable or direct to AIG, PO Box 1745, Shortland Auckland, 1140
More informationPersonal Accident / Illness Claim Form
Thank you for notifying us of your claim. Please complete this claim form and return it to: Specialty Claims Services PO Box 51541 LONDON SE1 0XU If you need any help in completing this form please contact
More informationPersonal Accident or Sickness Claim
INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Personal
More informationOnce we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible.
ACCIDENT CLAIM FORM Dear Claimant, We are sorry to learn of your accident. In order for us to process your claim, we require the following: 1) Claimant s Statement. 2) 1 Clinical Abstract Application Form.
More informationHealth & Safety The Compensation Fund 2013
The Compensation Fund provides compensation for workers who get hurt at work, or sick from diseases contracted at work, or for death as a result of these injuries or diseases. The Compensation Fund is
More informationINDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM
INDIVIDUAL TOTAL & PERMANENT DISABILITY (TPD) CLAIM FORM Dear claimant, We are sorry to learn about your disability. In order for us to process your claim, we require the following: (1) Claimant s Statement
More informationLiability Claims Guidance Notes
Liability Claims Guidance Notes It is important that you read and understand these guidance notes before When can a claim be made against the Council? completing the claim form To successfully claim compensation
More informationForm Workers compensation claim form
Form Workers compensation claim form Part 1 of the claim form is to be filled in by the worker. The following information is provided as guidance to workers filling in Part 1 Notify your employer of your
More informationPERSONAL ACCIDENT CLAIM FORM - MEMBERS
Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important
More informationTravel Insurance Claim Form
Jetstar Travel Travel Insurance Insurance Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for
More informationCOIDA ACCIDENT REPORTING
COMPENSATION FOR OCCUPATIONAL INJURIES & DISEASE ACT, 1993 Where the accident has caused death, unconsciousness or amputation or where the injured employee is presumed unable to work for a period of at
More informationClaim notification form (RTA1) Low value personal injury claims in road traffic accidents ( 1,000-25,000)
Date sent / / Claim notification form (RTA1) Low value personal injury claims in road traffic accidents ( 1,000-25,000) Before filling in this form you are encouraged to seek independent legal advice.
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationNATIONAL COUNCIL FOR ROAD SAFETY HIT & RUN ROAD TRAFFIC ACCIDENT VICTIMS CLAIM APPLICATION FORM (CAF/1)
NATIONAL COUNCIL FOR ROAD SAFETY NRSS-FORM No.CAF/1 HIT & RUN ROAD TRAFFIC ACCIDENT VICTIMS CLAIM APPLICATION FORM (CAF/1) CAF/1 Ref. No. (For office use only) SECTION 1 DECEASED /GRIEVOUS INJURY 1.1.
More informationWorkers Compensation Claim Form
Workers Compensation Claim Form Workers tear off and keep this section for your information Who can make a claim? You are entitled to make a claim if you sustain an injury in the course of your employment
More informationNotice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
More informationCLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE
CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE You fully complete every question before your doctor completes his statement.
More informationWorkers Compensation Claim Form
Workers Compensation Claim Form Insert insurer logo Workers tear off and keep this section for your information Who can make a claim? You are entitled to make a claim if you sustain an injury in the course
More informationHow To Get Compensation For An Accident In India
MODULE - 5 Public Liability Insurance Act 1991... 5 PUBLIC LIABILITY INSURANCE ACT 1991, AND WORKMEN COMPENSATION ACT 1923 AND MOTOR VEHICLE ACT 1988 5.0 INTRODUCTION In this chapter we will discuss various
More informationPostal Code ( ) Postal Code ( ) NRIC/FIN No.: Time of Accident/Injury:
www.libertyinsurance.com.sg Please complete all sections to facilitate the processing of your application. This form is issued without admission of liability and it must be completed and returned to us
More informationMotor Accident Personal Injury Claim Form
Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits
More informationPERSONAL ACCIDENT CLAIM FORM
PERSONAL ACCIDENT CLAIM FORM (Form to be completed in full or claims will be delayed) Insured s name Identity number (Please attach a certified copy of your ID) Postal address.. Code... Tel number Fax
More informationProtect Injury and Sickness
INSURANCE SOLUTIONS CLAIM FORM Protect Injury and Sickness EXTF058 For dental claims, please use the Protect Accidental Dental Injury claim form. Call ATC for assistance on 1800 994 694 1. You complete
More informationINDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM
INDIVIDUAL HOSPITAL & SURGICAL CLAIM FORM Dear claimant, We are sorry to learn about your hospitalization. In order for us to process your claim, we require the following: (1) Claimant s Statement (2)
More informationIndustrial Injury Allowance Policy
Industrial Injury Allowance Policy 1. Aim The aim of this policy is to provide information to managers on the reporting of industrial injury related absence, and the mechanisms available to support employees
More informationBERMUDA WORKMEN S COMPENSATION RULES OF COURT 1965 SR&O 14 / 1966
QUO FA T A F U E R N T BERMUDA WORKMEN S COMPENSATION RULES OF COURT 1965 SR&O 14 / 1966 [made under section 41 of the Workmen s Compensation Act 1965 brought into operation on 2 August 1965] TABLE OF
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationChecklist for personal accident, overseas student or foreign maid claim
Checklist for personal accident, overseas student or foreign maid claim Dear person claiming We are sorry to learn of your illness, injury or stay in hospital. Please send us all the documents listed below.
More informationHow To Write A Claim For A Car Accident
Compulsory Third Party Personal Injury Claim tification To claim damages for personal injuries in a motor vehicle accident, please complete this form in BLOCK LETTERS 2. Do you have a solicitor acting
More informationIN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI., ) Plaintiff, ) Case No. v. ) ), ) Defendant. )
TO PLAINTIFF IN THE CIRCUIT COURT OF GREENE COUNTY STATE OF MISSOURI, ) Plaintiff, ) Case No. v. ) ), ) Defendant. ) DEFENDANT S FIRST INTERROGATORIES DIRECTED TO PLAINTIFF Comes now defendant, and in
More informationKenya Proclamations, Rules and Regulations, /956 THE WORKMEN'S COMPENSATION ORDINANCE. (Cap. 119)
Kenya Proclamations, Rules and Regulations, /956 109 LEGAL NOTICE No. 63 THE WORKMEN'S COMPENSATION ORDINANCE (Cap. 119) (Lab. 24/5/5) IN EXERCISE of the powers conferred by section 42 of the Workmen's
More informationCorporate Travel Claim Form
Corporate Travel Claim Form Important Notice The acceptance of this Form is NOT an admission of liability on the part of Zurich Insurance Company Ltd (Singapore Branch) (the Company ). Any documentary
More informationFamily Name (surname) : Date of birth : Day Month Year First Name : Nationality ( citizenship ) : Telephone : Mobile Phone Number: Address :
Please affix passport photograph APPLICATION FORM SHORT TERM COURSE IN MALAYSIA UNDER THE MALAYSIAN TECHNICAL COOPERATION PROGRAMME ( MTCP ) Please type or write clearly in capital letters. Do not leave
More informationPost Code. Type of Business VAT registered? Yes No
PUBLIC LIABILITY CLAIM FORM Insured Insured Policy Number Post Code Type of Business VAT registered? Yes No Annual Turnover Non-clerical wage roll Contact Please provide details of the person we should
More informationSPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form
SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your
More informationMadison County Board Of Education
JOB-RELATED INJURY INSTRUCTIONS In compliance with Board Policy FILE: 5.9.4, Absences Due to Job-Related Injuries, the following instructions must be followed when injuries occur on the job. Please read
More informationIncident Reporting Manual
Pillar Income Asset Management, Inc. Incident Reporting Manual For use in reporting: Property Losses General Liability Incidents Workers Compensation Incidents Commercial Auto Incidents Prepared by: The
More informationSmartTraveller Claim Form
AXA Affin General Insurance Berhad (23820-W) Ground Floor Wisma Boustead 71 Jalan Raja Chulan 50200 Kuala Lumpur (603) 2170 8282 (603) 2031 7282 customer.service@axa.com.my www.axa.com.my SmartTraveller
More informationPersonal Accident Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form
More informationNotification Claim Form
Notification Claim Form Once completed, please return your claim form to: Intana Sussex House Perrymount Road Haywards Heath West Sussex RH16 1DN Thank you for notifying us of your claim. Please complete
More informationYour People, Protected. Sports group Personal Accident Claim Form
Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this
More informationMaritime Super Income Protection Claim Form
Maritime Super Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all
More informationPersonal Accident Claim Form
Personal Accident Claim Form Claimant Details Title Full Name Date of Birth Occupation Usual Country of Domicile Claimant Address: Contact Details Postcode: Daytime Telephone: Email Address: Wherever possible
More informationLIFE INSURANCE CLAIM APPLICATION FORMS
LIFE INSURANCE CLAIM APPLICATION FORMS INSTRUCTIONS ALL OF THE FOLLOWING PROPERLY COMPLETED FORMS ARE ESSENTIAL TO THE PROMPT PROCESSING OF YOUR CLAIM: INFORMATION RELEASE FORMS (Please complete both Information
More informationPERSONAL ACCIDENT DISABLEMENT CLAIM FORM
PERSONAL ACCIDENT DISABLEMENT CLAIM FORM FOR OFFICE USE ONLY Issuing office : Date of Issue : Claim No : ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LIMITED 46, Whites Road, Chennai-600 014. Telephone :
More information** EMPLOYEE S AUTHORISATION TO REFUND EMPLOYER BENEFIT ADVANCED DURING THE PERIOD OF INCAPACITY
I Claim Employment Injury Benefit for the period to as a result of an injury which arose out of my employment as stated briefly (if space is insufficient, continue on a separate sheet): Name(s) of Person(s)
More informationBasildon Council - Motor Vehicle Claim Form
Basildon Council - Motor Vehicle Claim Form Please ensure you read the following information before completing this claims form and that you complete this form thoroughly, failure to complete the form
More informationBasildon Council - Public Liability Claim Form
Basildon Council - Public Liability Claim Form Please ensure you read the following information before completing this claims form and that you complete this form thoroughly, failure to complete the form
More informationPersonal Accident and Sickness Claim Form
Submit via email Personal Accident and Sickness Claim Form Thank you for notifying us of your claim - Issue of this form is not an admission of liability PLEASE ENSURE You fully complete every question
More informationGroup Journey Injury Insurance
Group Journey Injury Insurance Claim form All relevant sections are to be answered in full. Please print your answers. Zurich does not admit liability by the issue of this form. It is issued to enable
More informationEquity accident claim form
In the event of an insured accident, you must return this competed claim form to Equity as soon as possible. Equity s address is Guild House, Upper St Martins Lane, London, WC2H 9EG. IMPORTANT: claims
More informationGuide for Injured Workers
Guide for Injured Workers This is a guide to Oklahoma workers' compensation law and rules. It is based on laws and rules in effect in 2015. Laws and rules can change by acts of the Legislature, rulemaking
More informationPERSONAL ACCIDENT BENEFITS CLAIM FORM
PERSONAL ACCIDENT BENEFITS CLAIM FORM Please note that we have to ensure that our claim form covers all types of claims. If you do not consider a question to be relevant to your circumstances please enter
More informationWORKERS COMPENSATION & YOUR RIGHTS
WORKERS COMPENSATION & YOUR RIGHTS 655 Florida Grove Road Mailing Address P.O. Box 760 Woodbridge, NJ 07095 (732) 324-7600 GILL & CHAMAS Raymond A. Gill, Jr.* Peter Chamas* James Pagliuca Michael J. Hanus
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More informationPersonal Injury Claim Form
ACE Insurance Limited ACE Insurance Limited GPO Box 4065 1800 688 640 claims phone ABN 23 001 642 020 ABN 23 001 642 020 Sydney NSW 2001 1800 815 675 customer service The ACE Building GPO Box 4065 Claims
More informationNotice of Claim. Last First Middle Area Code/ Telephone Number. Last First Middle Area Code/ Telephone Number
Claimant: Notice of Claim Last First Middle Area Code/ Telephone Number Street Address Additional Address City State Zip Date of Birth Social Security Number If Notices and correspondence in connection
More informationPublic Liability Insurance Claim Form
& Public Liability Insurance Claim Form Completing this Form Please answer all questions. This will help us to process your claim quickly. If you need more space to answer any of the questions or wish
More informationPolicy on the reporting of accidents, dangerous occurrences and occupational ill health
Policy on the reporting of accidents, dangerous occurrences and occupational ill health CONTENT PAGE 1. Introduction 2 2. University policy 2 3. Procedures and guidance 2 3.1 All accidents requiring first
More informationMotor Accident Report Form
Motor Accident Report Form Tel: 01423 876000 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: 01423 874127 INSURED Motor Accident Report Form Policy. Name Home Tel.. Work Tel..
More informationGUIDE TO PERSONAL INJURY/ACCIDENT CLAIMS
GUIDE TO PERSONAL INJURY/ACCIDENT CLAIMS At Richard Grogan & Associates we have Solicitors with significant experience and expertise who will advise and guide you through all matters relating to bringing
More informationA Transitional Work Program benefits employees in several ways:
Workmen s Compensation Policy Number: 7390 Effective Date: All employees of Snake River School District 52 are covered by Workmen's Compensation insurance for bodily injury, disease, or death caused by
More informationPayCover Income Protection Claim Form
PayCover Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim for
More informationExpiry Date. If you have selected Cheque please nominate payee
TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process
More informationEmployee s Report of Injury Form
Employee s Report of Injury Form Instructions: Employees shall use this form to report all work related injuries, illnesses, or near miss events (which could have caused an injury or illness) no matter
More informationMotor Accident Notification Form (MANF)
Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital
More informationIndividual Personal Accident Claim Form
Once completed, please return your claim form to: ONE Claims Ltd 1-4 Limes Court Conduit Lane Hoddesdon Hertfordshire EN11 8EP Thank you for notifying us of your claim. Please complete this claim form
More informationClaim notification form
Before filling in this form you are encouraged to seek independent legal advice. Date sent / / Claim notification form Low value personal injury claims in road traffic accidents( 1,000-10,000) Are you
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More information1. Personal Statement
journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is
More informationMODEL POLICY TO COMPLY WITH NEW OSHA INJURY REPORTING REQUIREMENTS
MODEL POLICY TO COMPLY WITH NEW OSHA INJURY REPORTING REQUIREMENTS XYZ COMPANY INCIDENT & INJURY REPORTING POLICY 1.0 Purpose It is the policy of XYZ Company (Company) that all incidents that result in
More information