FPG Insurance

Policy Holder

POLICY NUMBER *

NAME *

AGE *

OCCUPATION *

PRIVATE ADDRESS *

BUSINESS ADDRESS *

Accident

DATE OF ACCIDENT *

TIME OF ACCIDENT *

PLACE OF ACCIDENT *

STATE PRECISELY HOW THE ACCIDENT OCCURED *

NATURE & EXTENT OF INJURIES *

NAME AND ADDRESS OF WITNESS (IF ANY)

Disability

STATE THE NUMBER OF DAYS YOU HAVE BEEN ENTIRELY CONFINED TO YOUR BED, ROOM OR HOUSE BY THE DIRECTION OF YOUR MEDICAL ATTENDANT

CONFINED TO MY BED FOR

NUMBER OF DAYS

FROM

CONFINED TO MY ROOM FOR

NUMBER OF DAYS

FROM

CONFINED TO MY HOUSE FOR

NUMBER OF DAYS

FROM

STATE THE EXTENT AND DURATION OF YOUR INABILITY TO ATTEND TO YOUR BUSINESS OR OCCUPATION

I HAVE BEEN DISABLED TOTALLY FOR

NUMBER OF DAYS

FROM

I HAVE BEEN DISABLED PARTIALLY FOR

NUMBER OF DAYS

FROM

I AM NOW _____________ DISABLED. *

NOT AT ALL

TOTALLY

PARTIALLY

IF STILL DISABLED, HOW MUCH LONGER THE DISABILITY IS LIKELY TO CONTINUE

I RESUME WORKING ON

IF NOT YET WORKING, STATE APPROXIMATE DATE WHEN YOU EXPECT TO DO SO

GIVE THE NAME AND ADDRESS OF THE MEDICAL PRACTITIONER WHO IS, OR HAS BEEN ATTENDING TO YOU FOR THIS INJURY.

HAS HE OR ANY OTHER PRACTITIONER ATTENDED TO YOU PREVIOUSLY FOR ANY ILLNESS OR INJURY?

YES

ARE YOU ENTITLED TO CLAIM COMPENSATION FOR ACCIDENT INJURY FROM ANY OTHER COMPANY / COMPANIES?

YES

DO YOU WISH TO SUBMIT ANY PROPOSITION FOR AN IMMEDIATE SETTLEMENT?

Upload Documents

PERSONAL ACCIDENT FORM B

POLICE REPORT/INVESTIGATION REPORT

MEDICAL CERTIFICATE

HOSPITAL STATEMENT OF ACCOUNT/CHARGE SLIPS

ORIGINAL OFFICIAL RECEIPTS OF HOSPITAL BILLS/PROFESSIONAL FEES

ORIGINAL OFFICIAL RECEIPTS OF MEDICINES PURCHASED OUTSIDE THE HOSPITAL AND THEIR PRESCRIPTIONS.

ORIGINAL COPY OF DEATH CERTIFICATE

PROOF OF BENEFICIARY'S IDENTITY LIKE BIRTH CERTIFICATE, MARRIAGE CONTRACT (ORIGINAL)

OTHERS (I.E. AUTOPSY REPORT, MEDICO-LEGAL REPORT, PICTURES, NEWSPAPER CLIPPINGS)

Declaration

I HEREBY DECLARE, THAT I HAVE RECEIVED THE INJURIES ABOVE DESCRIBED BY VIOLENT, ACCIDENTAL, EXTERNAL AND VISIBLE MEANS, AND I CLAIM COMPENSATION UNDER THE ABOVE POLICY IN RESPECT THEREOF. I HEREBY WARRANT THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT I HAVE NOT WITHHELD FROM THE COMPANY ANY MATERIALS INFORMATION IN CONNECTION WITH THIS CLAIM.

I have read and understood and voluntarily agreed to the collection, use, and disclosure of my personal data in accordance with FPG Privacy Policy.