Accident compensation claim application

Claimant Details

Claimant First Name:

Claimant Last Name:

Date of Birth:

Gender:

Nationality:

Address:

Phone:

Alternate Phone:

E-mail:

Employment Details

Date employed:

Position at time of Incident:

Date position attained:

Training received for this position:

Incident Details

Date of incident:

Place of Incident:

Road traffic accident?

Accident type:

Average Earning 12 months prior to Accident (GMD):

Percentage of Disability (%):

Cause of Accident:

How long did it take to resume duties:

Duration type:

Number of hours for the first 3 months after resumption:

Treatment Cost (GMD):

Business Details

Business name:

Business address:

Business city:

Business phone:

Business alternate phone:

Business e-mail:

Business website:

Tax Identification No.:

Purpose of Claim:

Additional Information:

Date Employee Completed Form:

Additional Details

Attachments:

Select file …

Declaration

I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application.