Personal Accident Claim Form - Atlas Insurance (Page 3 of 3) in pdf

Personal Accident Claim Form - Atlas Insurance Page 3

Disablement

From

Prognosis (Please indicate

probable duration of disablement)

Confined to house

Unable to give attention to any occupation

Able to give some attention to his occupation

If patient has now fully recovered, date of recovery:

Dates and details of injuries from which he has

previously suffered:

I hereby certify having personally examined the above mentioned patient and that in my opinion the

disability arises solely as a result of the accident described above and that there are no other

circumstances tending to produce either total or partial disability.

Name &

Qualifications:

Address

Signature

Date

Any fee for this report is to be paid by the Insured.

Data Protection Notice

The Company (Atlas Insurance PCC Limited) implements strict controls over all electronic and manual personal

data. All data will be treated with the utmost confidentiality. Processing of personal data will relate to the

underwriting/endorsing of this policy; processing of claims; detecting, preventing and suppressing fraud and

the keeping of statistics.

The Company may exchange certain information with your broker, sub-agent,

appointed experts, other insurers or the Malta Insurance Association for these purposes. You may also request

access to and rectification of your personal data by writing to Atlas Insurance PCC Limited.

Note:

Correspondence and claims. All communications and claims received by you concerning the incident are to be

forwarded immediately to Atlas without acknowledgement to the sender.

Signature of Insured: ________________________________

Date: ___________________________

Name (in BLOCK Letters):

Registered Office: 48-50 Ta’ Xbiex Sea Front, Ta’ Xbiex XBX1021, Malta Company Registration Number: C5601

Tel: (356) 2343 5375 - Fax: (356) 2134 4666 .mt

Atlas Insurance PCC Limited, a cell company authorised by the Malta Financial Services Authority to carry on general insurance business.

Personal Accident Claim Form - Atlas Insurance Page 3