Personal Accident Claim Form - Atlas Insurance
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3Personal Accident Claim Form
The issuing of this form is not to be taken as an admission of liability by the Insurers
Policy No:
Claim No:
Intermediary:
Name of Insured:
I.D Card/
Co. Reg No.:
Address:
Tel/Mobile No:
E-mail:
Injured Person:
I.D Card/
Co. Reg No.:
Postal Address:
Trade or Occupation:
State the nature of
the accident, how it
occurred, and what
the Insured Person
was doing at that
time:
When did it occur?
Date:
Time:
Place of Accident:
Name and Addresses
of any Witnesses:
State as fully as
possible, the injuries
sustained:
Have injuries
previously been
sustained to the
same part or parts?
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