PCD-NM-F004

REV: B

PERSONAL ACCIDENT CLAIM FORM

AGENCY: I POLICY NO:
DATE OF LOSS / ACCIDENT:
ISSUANCE DATE: I ISSUED BY:

1. This form is issued without prejudice to any of the stipulations or conditions of the Company's Policy, and is not
being taken as a liability on the part of the Company.
2. This Form should be completed and returned within SEVEN DAYS of its receipt by the Insured.
3. It is essential that each question should be answered as fully and accurately as possible.
4. The medical report overleaf must be completed by a duly qualified and registered medical practitioner attending to
the injury mentioned.

INSURED'S PARTICULARS
Name of Insured:
Correspondence Address:

Contact No:

Business / Occupation:
Name of Injured Person (if not policyholder):
Correspondences Address:

Contact No.:

Business / Occupation:

Date of Birth: Sex:

Present Position Held / Occupation: Present Weekly Salary / Wages:
DESCRIPTION OF lOSS
Time of Accident: a.m. / p.m.
Location of Accident:
1. Please state how the accident occured.

2. Please state the injuries you have sustained.

3. Please give names & address of any person who

witnessed the accident.
If reported to the Polic, please provide us a copy of
the Police Report.

4 a) Please give the name and address of the Medical

Practitioner who attended to you after the accident.
b) Is he/she your usual medical attendant? If not.
please state reason why he/she was consulted.
 8a) Is there any previous medical history which have a)
contributed directly or indirectly to the accident or
which may likely to retard the Patient's recovery?

b) Is the Patient suffering from any physical defect or b)

illness irrespective of his injuries? YES / NO
If yes, please state the condition.

9a) What is the present condition of the injuries? a)

10a) State how long in your opionion the patient will be

so disabled:-

• Total Disablement - patient is completely / Total Disablement

totally unable to perform his / her work From to
• Partial Disablement - patient is able to Partial Disablement
perform part but not all of his / her work From to

11a) In your opinion, could the patient resume any a)

other work for which he/she is reasonably fitted
by education, training and experience? If yes,
please specify.

12a) Remarks a)

I hereby certify having examined the above Patient and that my foregoing statements are true
and correct to the best of my knowledge and belief.

Date: Signature:

Address:

Qualification:

Note:
TOTAL DISABLEMENT arises when the Patient is rendered completely incapable of attending to any
part of his ordinary profession business or occupation.
PARTIAL DISABLEMENT arises when the Patient's injury is minimal or has so far recovered from
injuries as to be capable of attending to some portion of his ordinary profession business or occupation.

KURNIA INSURANS (MALAYSIA) BERHAD (44191-P)

(A member of the Kumia Group of Companies)
HEAD OFFICE: Menara Kumia. NO.9, Jalan PJS 8/9. 46150 Petaling Jaya. P.O. Box 8607, 46792 Petaling Jaya. Selangor Darul Ehsan.
Tel: +603-7875 3333 Fax: +603-78759933 E-mail: corporale@kumia.comWebsile: www.kumia.com

BRANCHES:
Alor Setar: Tel: 04-7339888 Fax: 04-7305888 Batu Pahat: Tel: 07-4326333 Fax: 07-4323522 Butterworth: Tel: 04-3973888 Fax: 04-3978362 Ipoh: Tel: 05-2552846/48
Fax: 05-2413937 Johor Bahru: Tel: 07-2383328 Fax: 07-2383731 Johor Jaya: Tel: 07-3537233 Fax: 07-3570233 Kajang: Tel: 03-87338118 Fax: 03-87343737
Kangar: Tel: 04-9764226 Fax: 04-9768914 Kepong: Tel: 03-62578301 Fax: 03-62578251 Klang: Tel: 03-33428333 Fax: 03-33449775 Kluang: Tel: 07-7738000
Fax: 07-7722558 Kota Bharu: Tel: 09-7481033 Fax: 09-7449633 Kota Kinabalu: Tel: 088-232200 Fax: 088-232204 Kuala Lumpur: Tel: 03-26989333
Fax: 03-26989933 Kuala Terengganu: Tel: 09-6246561 Fax: 09-6246531 Kuantan: Tel: 09-5664527 Fax: 09-5661164 Kuching: Tel: 082-247288,082-250554
Fax: 082-250611 Mel aka: Tel: 06-2830928 Fax: 06-2822707 Miri: Tel: 085-420102 Fax: 085·420924 Penang: Tel: 04-2284473 Fax: 04-2299921 Segamat:
Tel: 07-9321299 Fax: 07-9328551 Selangor: Tel: 03-21481500 Fax: 03-21421446 Seremban: Tel: 06-7670333 Fax: 06-7672487 Sibu: Tel: 084-348333
Fax: 084·317766 Sitiawan: Tel: 05-6919333 Fax: 05-6911333 Sungai Petani: Tel: 04-4428333 Fax: 04-4428212 Taiping: Tel: 05-8086333 Fax: 05-8083223 Tawau:
Tel: 089-762633 Fax: 089-762533 Temerloh: Tel: 09-2960933 Fax: 09-2966933
 MEDICAL REPORT

1a) Name of Patient a)

b) NRIC No b)

c) Age c)

d) Sex d)

e) Occupation e)

2a) Are you his/her usual medical attendant? a)

b) Is Patient related to you? If so, please state nature . b)

of relationship.

c) How long have you known him/her? c)

d) Have you attended him/her for illness or accident d)

prior to this? If so, please give details i.e. type
diagnosis/injury & when.

3a) When did you first attend to the patient after the a)
accident?

b) Are you still attending to the patient? b)

4a) How did the accident happen? a)

5a) Please give full details of injuries. a)

b) For the loss of limbs or fingers, please state b) Clean cut c::=J Jagged cut c::=J
c) Are the injuries sustained consistent with the c)
circumstances of the accident as described to you
by the Patient?

d) If not, are they traceable to any other cause? d)

6a) Is the patient sober and of temperate habits?

b) Have you any reason to suspect that the Patient

.
was under the influence of intoxicants or drugs at
the time of accident?

7 a) Please give details of treatment given to Patient. a)

5. Please state: (a)
a) Whether you have been totally unable to attend to
any portion of your business I occupation. If so,
please give dates

1) TOTALLY 9isabled (1) From to

2) PARTIALLY disabled (2) From to

Both dates inclusive

6. Have you ever required any medical or surgical

treatment during the past 5 years? If so, please
give details.

7. Please state whether in respect of the accident you

are entitled to receive compensation from any other
source.
If so, what are the sources and to what extent?

8. Have you previously met with an accident for which

a claim was made for compensation in respect of
accidental injury from any Insurance Company?
If so, please give particulars.

9. If immediate settlement is desired, how much

compensation do you wish to claim?

I warrant that the above statements and particulars are correct and complete, and that no
information has been withheld.

.
Signature of Insured & Company Rubber Stamp Signature of Claimant
(if applicable)

Name & Ie No: Name & IC No:

Date: Date: