Form Acidentes Pessoais

Entry date

Modality/pruductProfessional risksExtra-prodessional

Policy No

Personal accident claim

Broker code

Branch

Broker’s name

THE COMPLETE FILLING OUT OF THIS CLAIM FORM AND THE SUBMISSION OF THE REQUIRED DOCUMENTATION WILL FACILITATE THE ASSESSMENT AND MAKE A QUICK DECISION ON THE REQUESTED CLAIM POSSIBLE.

1. Policyholder

Name

2. Injured person details (Insured person)

Full name

Street Address

City / Town

Postal code

Phone

Fax

Identity card / Personal ID

Tax ID (Nuit)

Date of birth

Bank account number (Nib)

Proof

No file chosen

3. Accident description

Date of accident

Time

Place of accident

Damages incurred / suffered

Detailed description of the accident (if necessary, use page 2)

Is the accident related to your profession?YesNo

Is the accident covered by any work accident policy?YesNo

Which company

Policy number and/or employer’s name

Does the accident have another personal accident insurance covering medical expenses?YesNo

Which company

Policy number?

What is the value?

Traffic accidentYesNo

If yes, provide vehicle license plate

Names of passengers

Identification of witnesses (if any)

Did the authorities record the occurrence?YesNo

CheckboxPRM

Station / Unit / Precinct

Police report number

Date

4. Required documents depending on main coverages

Medical expenses

Clinical information

Medical prescription (doctor’s note)

Original receipts (Pharmacy, Clinic, Hospital, etc.)

Temporary disability

Medical report

Diagnostic test results

Proof of wage reduction (if partial)

Proof of income (if total)

Hospitalization

Hospital statement (reason + period)

Partial permanent disability

Medical report (injuries, treatments, sequelae)

Diagnostic test results

Death

Certificate of heirs entitlement

No file chosen

Birth certificate (in case of minors)

No file chosen

Autopsy + toxicology report

No file chosen

Police report

No file chosen

Funeral expenses

Original funeral expense receipt

5. Declaration1. I hereby declare, for all due purposes, that the information provided by me is true and complete. I assume full responsibility for the accuracy of the information provided, being aware that any false or omitted information may have legal or administrative consequences, as applicable.2. I authorize the Insurance Company to collect additional personal data from public bodies, specialized companies, and other economic entities, with the purpose of confirming or complementing the information collected, necessary for the management of the contractual relationship. Omissions, inaccuracies, and falsehoods in the provision of information are my responsibility. Access to the provided personal data is granted under strict confidentiality, provided that it is compatible with the purpose for which the data was collected.