Courier Accident Claim Form

• Copy of the identification documents of the Insured person;
• Form 100
• Medical documents confirming the rendered medical researches (X-ray, Ultrasound, Computer Tomography, Magnetic Resonance Tomography etc.)to the Insured person by medical institution
• A Certificate from Ministry of Internal Affairs
• If necessary, all other documents which permit to determine the cause and consequences of the Insured event may be requested.

Medical Certificate
We will need the proof or you hospital stay

Any other document related to the accident
Police report, witness statement ...

Medical Certificate
We will need the proof or your dental injury

Any other document related to the accident
Police report, witness statement ...

• Copy of the identification documents of the Insured person;
• Discharge summary from the patient record, discharge from the patient history, medical certificate, medical documents confirming the rendered medical aid to the Insured person by medical institution, temporary disability sheets, certificates containing the exact description and character of a trauma, with indication of diagnosis, which was the reason for disability assignment certified with a medical institution seal;
• The documents (certified copies), concerning the circumstances of the Insured event, its reasons, expenses;
• If necessary the documents issued by corresponding authorized bodies of Georgia, confirming the occurrence of an event, which has attributes of the Insured event (fire services, police etc.);
• Confirmation from the employer on employment of the Insured person (or the copy of the individual employment agreement);
• Application on Insurance payment receipt and complete bank details of the Beneficiary;
• If necessary, all other documents which permit to determine the cause and consequences of the Insured event may be requested.

In case of death of the insured person

• Notarized copy of the Death certificate of the Insured person, issued by the state act of civil status registration bodies (Registry Authorities) of Georgia;
• Medical certificate and/or expertise conclusion on the reasons of death of the Insured person, or its copy;
• Final report of patho-anatomical (medico-legal) investigation, if available, or its notarized copy;
• Issued epicrisis from the patient’s card, case record, medical certificate, medical documents confirming the rendered medical aid to the Insured person by medical institution, certificates containing the trauma’s exact description and character, with indication of diagnosis, which was the reason of the Insured person’s death, certified by a medical institution’s stamp;
• If necessary the documents issued by corresponding authorized bodies of Georgia, confirming the occurrence of an event, which has attributes of the Insured event (fire services, police etc.);
• The documents (certified copies), concerning the circumstances of the Insured event, its reasons, expenses;
• Notarized copy of inheritance right certificate issued by the notary or notarized copy of properly issued will of the Insured person;
• Confirmation from the employer on employment of the Insured person (the copy of the individual employment agreement and documentations confirming payment of salary to the employee for the whole relevant period);
• Application on Insurance payment receipt and complete bank details of the Beneficiary;
• All other documents which permit to determine the cause and consequences of the Insured event may be requested.

In respect of the funeral cost

• Relevant receipts concerning Funeral expenses
• if necessary, all other documents which permit to determine the amount of Funeral costs may be requested;