Personal Accident Claim Form - Atlas Insurance Page 2
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1
2
3Give dates of inability to carry out usual duties:
Totally disabled
To:
Partially disabled
To:
Date first received
medical attention:
Name of Medical
Attendant
Address
Tel/Mobile No:
E-mail:
Give details of any
physical defect or
infirmities
Previous injuries
with dates and
periods of incapacity
Will any claim be made upon any other Company in respect of this accident?
Yes
No
If yes, please give
names of all
Companies
Declaration by the Insured
I, the undersigned, hereby declare that I am the person entitled to the benefit of the above Policy and I
solemnly affirm that the answers I have given are true.
Signature of Insured
Name in Blocks
Date
To be completed and signed by the Insured Person’s Medical Attendant
Name of Patient:
Age:
Trade or Occupation:
Are you the patient’s usual doctor?
Yes
No,?
If yes how long have
you known the
patient
Cause of incapacity:
Date first seen by
you in connection
with this incapacity:
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