DISABILITY CLAIM FORM Insured part

Policy Number:

Insured’s name:

ID Number:

Residence Address:

Telephones:

Work Address:

Telephones:

If disability is due to an illness or disease:

Yes

No

Commencement date of illness or disease:

Give details about the illness or disease:

Date of the Accident:

Time of the Accident:

:

Give details of the Accident

What treatment do you receive today?(surgical or not, medication or any other treatment)

Have you ever been treated in a hospital/ clinic for this incident or illness? If YES, when and where?