Personal Accident Insurance Claim form

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1 Personal Accident Insurance Claim form Please answer every applicable question and sign the declaration. Policy Number 1 Insured Name of your employer Department Address Postcode Contact telephone number (work) Contact address 2 Insured person Name of insured person Address of insured person Postcode Contact telephone number (if different from above) Contact address (if different from above) 1

2 3 Accident Please use the blank page at the back of the form for further space if required. When did the accident occur? Date Time am / pm Where did the accident happen? How did the accident happen? What were you doing at the time of the accident? Who witnessed the accident? Name of witness Address of witness Telephone number of witness 1) 2) 3) 2

3 4 Injuries What injuries have you sustained? (Please state in detail) Have you had this injury before? Yes No If Yes please provide further details. Please provide the name and address of the medical practitioner attending to your injuries Name Contact telephone number Address Postcode Is this your usual medical practitioner? Yes No If No please state why he/she is in attendance. 3

4 5 Incapacity Have you been totally incapacitated from attending your usual occupation as the direct result of the accident? Yes No If Yes please provide the date incapacity commenced Bed From To House From To Are you still totally incapacitated? Yes No If No are you now able to attend to a portion of your usual occupation? Yes No Date from Are you now able to attend all aspects of your usual occupation? Yes No Date from 6 Medical certificate The insured person must arrange at their own expense for the completion of this certificate by a qualified and registered Medical Practitioner. To comply with the Access to Medical Reports Act 1998, the certificate should be returned to the injured person before being sent to Zurich. Re: (Patients name) When did you first attend the patient in respect of his/her accident? Date Are you still attending the patient in respect of his/her accident? Yes No Are you the patient s usual Medical Practitioner? Yes No If Yes, since when has he/she been your patient? Date 4

5 Medical certificate - continued Please state in detail the nature and extent of the injuries. Are the symptoms, from which your patient suffers due to: The accident only Any other cause Is the patient now, or was he/she at the time of the accident, subject to or suffering from any illness irrespective of the injuries? Yes No If Yes, please state the nature and the extent to which recovery of the patient from the accident may be affected. Are you aware of any past accident or illness which directly or indirectly may contribute to or retard the patient s recovery? Yes No Is the patient confined to bed or residence based on your instructions? Yes No If Yes what is likely to be the probable period of total incapacity? 5

6 Medical certificate - continued General remarks Signature of medical practitioner 7 Declaration from the insured person I declare that all answers are true and correct. Signature Date Please send this completed claim form with all supporting documents to: Zurich GCUK Casualty Claims Team 3000C Parkway Whiteley Fareham PO15 7JZ Telephone number

7 8 Additional information 7

8 Zurich Global Corporate UK London Underwriting Centre, 3 Minster Court, Mincing Lane, London EC3R 7DD, England. Zurich Global Corporate UK is a trading name for the following company: Zurich Insurance Ireland Limited A limited company incorporated in the Republic of Ireland Registered No UK Branch registered in England and Wales No. BR7985. Registered Office: Eagle Star House, Ballsbridge Park, Dublin 4. Head Office in the UK: London Underwriting Centre, 3 Minster Court, Mincing Lane, London EC3R 7DD. Authorised and regulated by the Irish Financial Regulator and regulated by the Financial Services Authority for the conduct of UK business.

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