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  • GPA Claim Form

    Transféré par

    subasratna
    54 vues2 pages
    This document is a Group Personal Accident Claim Form for Siddhartha Insurance Limited. It requests information such as the insured's name and address, policy details, details of the accident, medical treatment received, salary and compensation received, and a declaration that the details provided are true. The form must be signed and dated before being submitted to Siddhartha Insurance Limited.

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    htdhyedt

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    This document is a Group Personal Accident Claim Form for Siddhartha Insurance Limited. It requests information such as the insured's name and address, policy details, details of the accident, medical treatment received, salary and compensation received, and a declaration that the details provided are true. The form must be signed and dated before being submitted to Siddhartha Insurance Limited.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    54 vues2 pages

    GPA Claim Form

    Transféré par

    subasratna
    This document is a Group Personal Accident Claim Form for Siddhartha Insurance Limited. It requests information such as the insured's name and address, policy details, details of the accident, medical treatment received, salary and compensation received, and a declaration that the details provided are true. The form must be signed and dated before being submitted to Siddhartha Insurance Limited.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 2

    Siddhartha Insurance Limited

    Head Office : Siddhartha Insurance Bhawan, Babarmahal P. O. Box 24876 Kathmandu, Nepal.
    Tel. No. 977-1-4257766, Fax No. 977-1-4257776, E-mail: info@siddharthainsurance.com.

    GROUP PERSONAL ACCIDENT CLAIM FORM

    1. Insured's Name & Full Address :_________________________________________


    2. Telephone No: :___________________________________
    3. Name of injured person :_________________________________________
    4. His/Her residence address :_________________________________________
    5. Telephone No: :___________________________________
    6. Policy No: ____________________ Period of Insurance From :______________
    To :______________
    7. Date of accident: _____________Time :___________Place of accident____________
    8. Full details how accident occurred :
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    _______________________________________________________________________

    9. Name & Address of the witness :_________________________________________


    10. Name, Qualification & Address of the attending doctor/surgeon:
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________

    11. Period of complete confinement to


    Bed/room/hospital From:__________________ To ;_______________
    12. Period of complete confinement to house only From:_____________To___________
    13. If any part of your business work is attended by the injured person in respect of (13)
    above, please give details:
    ________________________________________________________________________
    ________________________________________________________________________
    14. Details of compensation, if any, paid to him/her during confinement period:
    ________________________________________________________________________
    ________________________________________________________________________

    15. Please specify monthly salary of the injured person: __________________________


    16. If insured elsewhere, please enclose policy copy:_____________________________
    17. Do you wish to add any additional information? If so, please give details:
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________

    I / We declare that the above statements are true to the best of my / our knowledge.

    Date:__________________ Signature with Official Seal / Stamp.

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