Personal Accident and Illness Claims

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Claim Form - Personal Accident and Illness

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Is your claim for an accident or illness?
For Accident Claims - Address Where Incident Occurred
Witness Details
Have you previously been treated for any serious injury?
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Have you had this complaint before?
Was hospital treatment required?
Hospital/Medical Centre Details
Name
Address
Doctor's Name
 
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Is this doctor still treating you for the injury / illness?
Is this doctor your regular doctor?
Your Regular Doctor Details
Name
Address
 
Is there any condition (past or present) affecting your current disability?
Are you now:
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Have you made, or will you make, a claim for benefits under any Workers’ Compensation Act or Transportation Act because of this injury?
Are you entitled to claim benefits for this Injury / Illness from other Insurers, Persons, Company, Health Fund, Friendly Society or Government?
Name(Required)
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Drop files here or
Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB.