Claim Form - Injury / Illness

Injury / Illness
Where did accident / illness occur ?
Date of accident / illness

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Give full particulars of the accident and nature of injuries or name of the illness:

Disablement
Period of temporary total disablement
Period of temporary partial disablement
Given date normal occupation resumed

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Has any permanent disablement resulted
If Yes, please specify details of permanent disablement

Other Insurances
Does the insured person have any other insurance in place, if so please provide details below
Previous Claims
Give details of all claims against insurers or in terms of the WCA by the insured person. Compensation for Occupation Injuries and Diseases Act No. 150 of 1993

Declaration
I / We declare that the above particulars are true in every respect.
Insured's Signature
Capacity
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
IMPORTANT

I hereby authorise any hospital, physician, or other person who has attended or examined me, to furnish to the company,
or its authorised representative all information with respect to any illness or injury, medical history, consultation,
prescriptions or tretment, and copies of all hospital or medical records.

A photostat copy of this authorisation shall be considered as effective and valid as the original.
Insured's Signature
Capacity
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How we handle your personal information:

We are committed to handling your personal information in confidence.

We need to collect, use, and disclose your personal information to consider your application and to provide the insurances needed, including the required on-going servicing of your policy. We will share your personal and risk information with Insurers, claims providers and suppliers. Any information provided to us may be stored in a shared database and used by Insurers. This includes information regarding the renewal or continuation of your policy or any claim that you may submit. This information may be checked against other legal sources or databases insofar as it relates to the servicing of your policy.
Should be Empty:

Injury / Illness Claim Form