Consumer Credit Insurance Claim Form - Avea Insurance Page 3
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4SECTION 5: MEDICAL ATTENDANT’S REPORT
(TO BE COMPLETED BY TREATING DOCTOR)
1.Name of Claimant:
2.Occupation:
3.Are you the Claimant’s usual medical attendant?
4.State the exact nature and extent of injuries sustained or all illness/disabilities suffered by the Claimant:
5.What organs are affected (state whether mild or severe)?
6.On what date did you first attend the Claimant in connection with his/her present disablement?
/
/
7.Was there any external and visible sign of injury?
YES
NO
If YES, give details:
8.In your opinion would the symptoms have been evident to the Claimant for any length of time?
9.State period that the claimant:
a)
will be totally unable to attend his/her usual occupation or business:
From:
/
/
To:
/
/
b)
has been totally unable to attend his/her usual occupation or business:
From:
/
/
To:
/
/
10.When did he/she or at what date do you expect that the Claimant will be able to resume:
a)
some part of his/her work?
From:
/
/
To:
/
/
b)
the whole part?
From:
/
/
To:
/
/
11.Has the treatment or medicine prescribed by you been adhered to by the Claimant:
YES
NO
12.Are you aware of the claimant previously suffering from this condition:
YES
NO
If YES please provide FULL details:
13.Has the Claimant previously suffered from any illness which would have contributed to or would have accelerated the occurrence of the Claimaint’s current medical
condition:
YES
NO
If YES please provide FULL details:
GENERAL REMARKS
Name:
Qualifications:
Address:
P/Code:
Signature:
Date:
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