Personal
Accident Claim
Phillips House
12 Church Street
Harwich
Essex CO12 3DS
Phone: 01255 553039
Email: [email protected]
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
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.
Personal Accident Claim.
Section 1. Your Details
Full Name(s)
2
Address
Telephone Number
Day
Eve
Mobile
Have you smoked any cigars or cigarettes in the last 12 months? Y/N
Age
Height
Weight
NI Number
Grade / Occupation
Business Address
Nature of Business
Personal Accident Claim.
Section 2. Accident
Date and Time of Accident.
3
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.
Personal Accident Claim.
Section 3. Hospital Benefit.
4
Were you admitted to hospital as a result of your accident?
Y/N
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.
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?
5
Are you still unable to work or engage in your usual activities? Y/N
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?
Y/N
If “No” then who is?
Are you claiming any other insurance?
Y/N
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.
Personal Accident Claim.
Section 7. Medical Certificate.
1. Name and address of Claimant.
6
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.
Y/N
4. Has the claimant been able to attend to any portion of his/her usual
occupation?
Y/N
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?
Y/N
7. Are you are aware of anything in the claimants previous history which may
be likely to delay his or her recovery?
Y/N
If “Yes” please give details.
Personal Accident Claim
Section 7. (Continued)
8.
When do you expect the claimant to return to work?
7
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? Y/N
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? Y/N
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