Employers' Liability Claim Form

Employers’ Liability Claim Form

THE ISSUE OF THIS FORM DOES NOT IMPLY ADMISSION OF LIABILITY ON THE PART OF SACOS. THE INSURED IS REQUESTED TO ANSWER ALL QUESTIONS FULLY AND RETURN WITHOUT DELAY. DASHES ARE INSUFFICIENT.
1. INSURED
Name*
Address*
Trade or business*
Telephone*
2. POLICY
Policy number*
Period of insurance*
3. DETAILS OF ACCIDENT
Date*
Time (a.m. or p.m.)*
Place*
Brief details of accident*
Did Police take particulars?*

YesNo
If so, from which Police Station?
Note: Please upload relevant statements and reports from victims, eyewitnesses, Police, etc.
Upload files

Cancelof
4. DETAILS OF PERSONAL INJURIES
a) Details of the person injured
Name*
Age*
Occupation *
Length of employment in present job*
Current monthly salary*
Nature of injuries*
b) Name and address of hospital/clinic attended*
c) Did Police take particulars?*

YesNo
d) (i) Has any claim been made upon you?*

YesNo
(ii) If so, by whom and what amount?
Note: Any correspondence must be forwarded immediately to Sacos.
e) Has employee resumed work?*

YesNo
If so, when?
f) Have you in any way admitted liability?*
g) In your opinion who was negligent?*
h) Give names and addresses of witnesses
Note: Please upload statements from witnesses.
Upload files

Cancelof
I/We have declared the foregoing particulars to be true to the best of my/our knowledge and belief, and I/We further declare that I/We do not hold any other policy indemnifying me/us in respect of this accident.
Signature of insured
Please sign using your finger (Smartphone) or mouse (PC/Mac).*

Clear
Please verify that you are human by keying in the word shown below*
If more than one person has been injured, please fill in a second form.
SAC102-0319
Should be Empty:

Employers’ Liability Claim Form

1. INSURED

2. POLICY

3. DETAILS OF ACCIDENT

4. DETAILS OF PERSONAL INJURIES