Name of the Insured
Town County
Postcode Date Premium Paid
Telephone Number Policy Number
Value Added Tax. Are you a registered person or company? Yes No
Age Height Weight
You the Policyholder
Circumstances of the Claim
a Occupation (please state all if more than one)
Brief description of job content i.e. usual duties and responsibilities
b Are you self employed? Yes No
If yes, give particulars of clerical or supervisory duties
Name and address of employers
d Nature of present incapacity
e Brief history of all previous illness/accidents including any earlier
incapacity as a result of present condition. Please give approximate
f When were you first medically treated for present condition?
g Name and address of doctor in attendance
If not your usual doctor also give his/her name and address
Personal Accident Claim Form
NIG Commercial Claims P O Box 1151 Bromley BR1 9WB
Please note - you can complete this form on screen. When completing please use the tab and arrow keys to move between the relevant
fields. Ensure you do not use the return or enter keys.
If completing by hand, please answer all questions using BLOCK CAPITALS.
h State if totally or partially disable and give details.
Note: Total disablement arises when a claimant is continuously
unable to attend to any part of usual occupation
from to
ii Partially
from to
i Has incapacity confined you to
i Bed
rom to
ii House
from to
j Give date of return or expected return to work
k Are you claiming under any other policy? Yes No
If yes, state name of insurance company and policy no.
ircumstances of the Claim
a Date (dd/mm/yyyy) Time
am pm
b Place
c State activity/occupation actually engaged in at time of the accident
d If taking part in organised sport state:
i amateur or professional capacity
ii name of Club/Team you were representing
e Please describe accident
I declare that the answers given are to the best of my knowledge and
belief true and comply in all aspects. I have no objection to the
Company approaching the doctor for a full report on my present
condition or previous medical history.
Signature Date (dd/mm/yyyy)
Please ask for the doctors co-operation in completing the medical
report below which must be returned as soon as possible after
accident, whether or not fully recovered
Accident Report
a Where and when did you first attend Patient in consequences of
present incapacity?
b Describe nature of present condition/injuries
c If incapacity is the result of an accident are the injuries solely and
directly attributable to and consistant with accident described by
the patient?
d Have you previously treated the patients for the present conditions?
Yes No
If yes, please give brief details
Medical Report (to be completed by Doctor)
e Are you aware of anything in patient’s previous history which may
contribute or prolong present incapacity? If so please advise details
f Please state period during which unable to attend to any part of
usual duties or occupation (dd/mm/yyyy)
From to
g P
robable further duration
h Please state period during which able to attend to some part if not
all usual duties or occupation (dd/mm/yyyy)
From to
i Probable further duration
j Date of return or expected return to work
k Remarks
Signature Date (dd/mm/yyyy)
edical Report (to be completed by Doctor)
NIG policies are underwritten by U K Insurance Limited, Registered office: The Wharf, Neville Street, Leeds LS1 4AZ.
Registered in England and Wales No 1179980. U K Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Calls may be recorded.