Consumer Credit Insurance Claim Form - Avea Insurance Page 2
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4SECTION 4: ACCIDENT
When did the accident occur:
Date:
/
/
Time:
am/pm
State exactly how the accident occurred:
Nature and extent of injuries: (if a limb or an eye, state whether left or right)
Name and address of all witnesses of the accident
Witness #1
Name:
Address:
Witness #2
Name:
Address:
Witness #3
Name:
Address:
Witness #4
Name:
Address:
Have you suffered from or sought treatment previously for the disability in respect of which you are now claiming: YES
NO
If YES, give details including date you last sought treatment:
Period for which you are claiming:
From:
/
/
To:
/
/
PLEASE NOTE
1.
If you are claiming for an accident or an illness, then Section 5 must be completed by your Medical Attendant. You are also
reminded that any charge for completion of that Report must be borne by you as per the terms of your policy.
2.
You signature is required in Section 7 of this form before lodgement.
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