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
i Has incapacity confined you 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
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
a Where and when did you first attend Patient in consequences of
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
d Have you previously treated the patients for the present conditions?
If yes, please give brief details
Medical Report (to be completed by Doctor)