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.
