Importantnotice:-Theissueof Thisform Is Nottobetakenasanadmissionof Liability

PERSONALACCIDENTCLAIMFORM

PolicyNO. P.A…………………….ClaimNo………………………………..

ImportantNotice:-Theissueof thisform is nottobetakenasanadmissionof liability.

FORMTOBECOMPLETEDBYTHEINSURED.

1.(a) NameofInsured(infull)

(b)Addressinfull

(c)Professionoroccupation(d)Agelastbirthday

2.(a) No.of Policy(b)DateofPolicy(c)Dateof lastpaymentofpremium

3.(a) Dateandtimewhenaccidentoccurredonthedayof

(date)(month)

20atO'clockInthe

(b)Whereit happened

(c)NameandaddressofWitness

4.Howdidthe accidentoccur?

5.Natureofinjuryreceived:

(if tolimboreye,statewhetherright orleft)

6.(a)Natureof disablement

(b)Extentofdisablement Confinedtohouse from to Partialdisablement from to

(d)Presentstateofincapacity

7.NameandAddressofSurgeonorDoctorinAttendance

8.(a)Whereand whencana MedicalOfficerof theCompanyvisityouifnecessary?

(b)Nameof nearestRailwayStationanddistancetherefrom

9.(a)AreyouinsuredinanyotherOfficeor Officesgrantingcompensationforaccident?

(b) Ifsostatenameandaddressof CompanyorCompaniesandamountof insurance

10.IfyouareclaimingforTemporaryTotalDisablement,doesyour weeklyincomeimmediatelybeforetheaccident

exceedby50%thetotalweeklycompensation you willreceivenowfrom thisandallothersources?

Ihereby declare thattheforegoingstatementsaremadeby myselfandaretrueinallrespectsandthatIhavenotattemptedtoconcealfromtheCompanyanythingwithwhichitoughttobemadeacquainted,andalsothatIhavenotabstainedfrommyusualoccupationlongerthanisabsolutelynecessary;andIagreethatifIhavemade,or,inanyfurtherdeclarationtheCompanymayrequire,shallmakeanyfalseorfraudulentstatementoranysuppression,concealmentoruntrueavertmentwhatever,thePolicyshallbevoid,andmy righttocompensationabsolutelyforfeitedandIamwilling,ifrequired,tomakeaStatutory DeclarationbeforeaJusticeofthePeaceofthetruthofthewholeoftheforegoingstatementoranyotherstatementImakeinconnectionwiththisClaim.

Sarchi Insurance Agencies Ltd | P.O. Box 40523, 00100, Nairobi, Kenya | Tel: +254 20 3545841/2

Witness: Address:

SignatueofClaimant: Date:

Sarchi Insurance Agencies Ltd | P.O. Box 40523, 00100, Nairobi, Kenya | Tel: +254 20 3545841/2

CERTIFICATETOBE FILLEDUPANDSIGNEDBYANEYEWITNESSOFTHEACCIDENT.

IherebycertifythatI waspresent whenthe AccidentoccuredtoMr

onthedayof20inthemannerstatedbyhimoverleaf,that it *wascaused by

wasnotcaused

his wilfulact, andthathe wasnotunderthe influenceof intoxicatingliquorat thetime.

Signature: Name: Address:

Occupation Date:

Strikeout whichisnotapplicable.

Sarchi Insurance Agencies Ltd | P.O. Box 40523, 00100, Nairobi, Kenya | Tel: +254 20 3545841/2