UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014

Personal Accident Insurance Claim Form (Particulars) of Accident)
The issue to this form is not to be taken as an admission of Liability

Policy No. ________________________
Claim No.
TO BE COMPLETED BY THE INSURED
1. (a) Name of the Insured [in full] ___________________________________
(b) Name of the injured Person
(c) Address in full
(d) Profession or occupation
(e) Age at last birthday
2.
Policy No. Sum Insured Table of Cover Period
(i)
(ii)
(iii)
3 a) Date of the accident?
Time of accident?
Place of Accident?
Name and address of witness
4 How did the accident occur ?
5. Nature of injury received
(If to limb or eye state whether
right or left)
6. a) Nature of disablement
Extent of disablement
Confined to bed
Confined to house
b) Present state of incapacity
[ from ________________ To
________________]
[ from ________________ To
________________]
7. Name and address of surgeon in
attendance
8. a) Where and when can a Medical
Officer of the Company visit
you, if necessary ?
Name of nearest railway station
and distance therefrom
9. a) Are you insured in any other
office or offices granting
compensation for accident
If so state name and address of
company or companies and amount
of insurance
I hereby declare that the foregoing statements are made by myself and are true in
all respect and that I have not attempted to conceal from the Company anything
which it ought to be made acquainted and also that I have not abstained from any
usual occupation longer than absolutely necessary and I agree that if I have made, or
in any further declaration the Company may require, shall make any false or
fraudulent statement or any suppression, concealment or untrue averment whatever,
the Policy shall be void and my right to compensation forfeited and am willing, if
required to make a Statutory Declaration before a Justice of the Peace of the truth of
the whole of the foregoing statement or any other statement I may make a
connection with this claim.
Witness:
Name______________________ Signature of the Insured_________________
Signature Date :
Date
Address
CERTIFIED TO BE FILLED UP AND SIGNED BY AN EYE WITNESS TO THE ACCIDENT
I hereby certify that I was present when the Accident occurred to
Mr._____________________________ On the _________________________________ day of
_____________________________ 20 ___ in the manner stated by him over leaf, that it was
caused by _____________________________ which * was / was not his willful act and that he *
was/was not under the influence of intoxicating liquor at the time
Signature
_________________________
Address __________________________
* Strike out which is not applicable Occupation ________________________
Date _____________________________
MEDICAL CERTIFICATE
Claims must be Supported by medical Evidence furnished by the Insured and at his expense.
1. (a) Name of Claimant (b) Sex (c) Age
2. (b) Nature and cause of accident
(b) If to eye or limb, state left or right
(c) Whether the appearance of the Injuries are consistent
with the account given of the accident.
3. Date on which you first attended Claimant for this injury
4. Has Claimant been totally prevented from attending
to any portion of his business ? If so how long ?
1. Is Claimant suffering from any disease or illness apart
From his injury and is there any illness by circumstances
Which may tend to retard recovery? If so, give particulars?
2. Present Condition
7. How long from the happening of the Accident do you consider
Total disablement will last ?
Having personally examined the above named Insured I certify that the above statements are
correct and that the injured person is necessarily disabled by the Accident referred to
Signature
_________________________
Name & Qualification________________
Address __ ________________________
Date _____________________________
REMARKS FOR EXTRA DETAILS