Personal Accident Claim
The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to
ALLIANZ NIGERIA INSURANCE PLC
Policy No
*
Name
Address
E-Mail:
*
Telephone Number
*
Occupation
Date of Accident
Time of Accident
Place
How did the accident happen and what were you doing at the time
Name and address of any witness of the accident
What injuries did you sustain
Name and address of the doctor attending to you
Is he/she your usual doctor
please select
Yes
No
How long have you been totally disabled?
From
To
How long have you been partially disabled?
From
To
Have you required medical or surgical treatment during the past five (5) years
please select
Yes
No
If so, please give particulars
Are you claiming under any other policy for this accident
please select
Yes
No
If so, please give details
Declaration
I declare that the above answers are true and complete
Insured's Signature
Date
Submit
Send Filled Content
Receivers' Email