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Personal Accident Or Illness Claim Form

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Personal Accident  

Or Illness Claim Form 

    Page:  7   

 

 

Medical Questionnaire to be completed by Claimants’ usual GP    The claimant must obtain, at his or her own expense, the completion of the following Certificate from a  duly qualified and Registered Medical Practitioner. 

Are you the usual Medical Attendant of the Claimant?  Yes       No 

(8)

 

Personal Accident  

Or Illness Claim Form 

    Page:  8        Is the disability due to self‐inflicted injury, consumption of alcohol, drug abuse, childbirth,  pregnancy, abortion or venereal disease or other sexually transmitted disease or HIV related  illness including Acquired Immune Deficiency Syndrome (A.I.D.S) or A.I.D.S Related Complex  (A.R.C)?          Yes        No  If YES, please provide details:     

Is the claimant presently confined to their home?  Yes       No 

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