Fogg Insurance Agencies Limited La Concorde
Triq Abate Rigord Ta’ Xbiex XBX 1121 , Malta Tel : (+356) 23422000 Fax : 21239416 E-mail: insurance@fogg.com.mt Website: www.fogg.com.mt
Please return this form together with the respective documents (i.e. Payslips / FS3 / Medical Certificate / NI30) to the above address. This Form must be completed by the Employer and returned to the Company immediately. You are kindly requested to answer in full all questions. You are obliged to provide us with the relevant reports to substantiate your claim together with any documents received.
Claim Number Branch / Broker / TII
Policy No.
Period of Insurance to
Limit of Indemnity €
Name of Insured
I.D. Number or Co. Reg. No. VAT Reg. No.
VAT Status Contact Person
Occupation / Nature of Business Tel. No. / Mobile No.
E-mail Address Postal Address
1. Name of Injured Person(s)
2. Address of Injured Person(s)
Section 1 - Insured Details
Section 2 - General Questions
3. Is/are the Injured Employee(s) employed on a Full or Part-Time Basis?
4. E-mail Address(es) of the Injured Employee(s) 5. Contact Telephone Numbers
6. National Insurance Number(s) 7. Identity Card Number(s) 8. Occupation(s)
9. Age(s)
10. Status (Single or Married)
11. Does/do the Spouse(s) of the Injured Person(s) (if applicable) work on a Full Time Basis? If yes, please provide details
12. Does/do the Injured Person(s) have any dependants? If yes, please provide details 13. Name and Address of Family Doctor(s) 14. Date of Employment
15. Gross Weekly/Monthly Earnings
(Please attach relevant FS3 / FS4 or Payslip) 16. Weekly Social Security Payments
17. Amount of Injury Leave Benefit / Due 18. Does/do the Injured Person(s) work a 5 or
6 day week?
19. Date and Time of Accident
20. Give a detailed explanation of how the accident occurred.
(Attach a signed statement if space is not enough)
21. State the nature of the injury(ies)
(e.g. If limb or eye please state left or right)
22. If Machinery was involved, please give details of make, type and manufacture.
23. Address of premises where the accident occurred and description of site
24. Was/were the Injured Person(s) performing a duty for which he/she/they were employed for? 25. Was/were the Injured Person(s) disobeying or
company rules or orders?
26. Was anyone responsible for the accident by virtue of negligence or other reason? If yes, please provide details
27. When and by whom was the accident reported to you?
28. What was the nature of the work that was being undertaken at the time of the accident?
29. Who was in charge?
30. Did the accident arise from any person(s) in your employ?
If yes, please provide full details (including Name and Address)
31. Did the Injured Person(s) stop work immediately? If not, please advise when the Injured Person(s) ceased work.
32. How long do you expect the injured Employee(s) to be away from work and be in a position to resume duties again?
33. Has/Have the Injured Employee(s) made a claim against you?
If yes, please provide details
(Any letter or document you receive should be forwarded to us immediately and unanswered) 34. Did anyone assume responsibility for the accident?
35. Give the Name(s) and Address(es) of any Witness(es) of the accident.
36. Was the accident reported to the Police? If yes, which Station and when?
37. Please provide details of who informed the Police? 38. Have similar accidents occurred in the past?
If yes, please provide details
39. Name or Doctor / Hospital by whom treatment was given.
40. Have you any other Insurance or Indemnity covering accidents to your employees? If yes, please provide details
Please provide us with the following documents :-National Insurance Injury Certificate (NI30) Manager's Report of Accident
Medical Certificates Evidence of Gross Earnings
Section 2 - Documents Required
IN TERMS OF THE DATA PROTECTION ACT (CHAPTER 440 OF THE LAWS OF MALTA) WE MAY OBTAIN PERSONAL DATA RELATING TO YOU FROM OUR TIED INSURANCE INTERMEDIARIES, OTHER INSURANCE COMPANIES, THEIR AGENTS AND TIED INSURANCE INTERMEDIARIES, OTHER INTERMEDIARIES AND BROKERS.
WE MAY ALSO BE OBLIGED TO DISCLOSE YOUR PERSONAL DATA TO COMPETENT AUTHORITIES ACCORDING TO LAW.
Data Protection Notice
TO THE EXTENT THAT THE INFORMATION SUPPLIED BY YOU CONSTITUTES PERSONAL DATA, YOU CONSENT TO THE PROCESSING OF SUCH DATA FOR PURPOSES OF ADMINISTERING YOUR PROPOSAL FOR INSURANCE, YOUR POLICY, UNDERWRITING, HANDLING OF CLAIMS, AND ALSO FOR THE PURPOSE OF DETECTING, PREVENTING AND SUPPRESSING FRAUD AND OF KEEPING STATISTICS.
I/WE DECLARE THAT THE STATEMENTS MADE ARE TRUE TO THE BEST OF MY /OUR KNOWLEDGE AND BELIEF AND FULLY AGREE WITH THE
INSURED'S SIGNATURE DATE
:-Argus Insurance Company (Europe) Limited
P.O. Box 45, Regal House, 3 Queensway, Gibraltar. Tel 79520 Fax 70942 Registered in Gibraltar No 1862. Registered Office : Regal House, Queensway, Gibraltar
Licenced by the Financial Services Commission No: FSC00027B Origins on the Rock of Gibraltar dating back to 1841
WHILST WE SHALL ENDEAVOUR TO OBTAIN YOUR WRITTEN CONSENT IN THE EVENT THAT WE NEED TO DISCLOSE TO THIRD PARTIES ANY PERSONAL DATA RELATING TO YOU, UPON SIGNING THIS FORM, YOU ARE AUTOMATICALLY PROVIDING US WITH YOUR UNEQUIVOCAL AND IRREVOCABLE CONSENT TO TRANSFER, SHARE, DISCLOSE OR EXCHANGE THIS DATA WITH OTHER INSURANCE COMPANIES, INSURANCE INTERMEDIARIES, INSURANCE MANAGERS, REINSURERS, INSURANCE ASSOCIATIONS INCLUDING THE MALTA INSURANCE ASSOCIATION,
INSTITUTIONS, CREDIT AGENCIES, INSURANCE SURVEYORS, LOSS ADJUSTORS, INSURANCE CLAIMS INVESTIGATORS OR ANY OTHER MARKET ENTITY FOR UNDERWRITING AND CLAIMS HANDLING PURPOSES, AND ALSO FOR THE PURPOSES OF DETECTING , PREVENTING AND SUPPRESSING FRAUD AND OF KEEPING STATISTICS, AND TO OBTAIN PERSONAL DATA RELATING TO YOU FROM MEMBERS OF THE MEDICAL PROFESSION, HOSPITALS, CLINICS, LABORATORIES OR SIMILAR INSTITUTIONS, BANKS, INSURANCE ASSOCIATIONS OR ANY OTHER ORGANISATIONS OR PERSONS. THIS ALSO HELPS US TO CHECK INFORMATION PROVIDED. WHEN WE DEAL WITH YOUR REQUEST FOR INSURANCE WE MAY SEARCH THIS INFORMATION. WHEN YOU TELL US ABOUT AN INCIDENT WHICH MAY OR MAY NOT GIVE RISE TO A CLAIM, WE MAY PASS INFORMATION RELATING TO IT TO THE MALTA INSURANCE ASSOCIATION AND OTHER INSURANCE COMPANIES OR ENTITIES.
WE AND OTHER COMPANIES WITHIN OUR GROUP WOULD LIKE, ON OCCASION, TO KEEP YOU INFORMED ABOUT OUR PRODUCTS AND SERVICES, BY MAIL, FAX, EMAIL OR OTHER ELECTRONIC MEANS. PLEASE INFORM US IN WRITING IF YOU DO NOT WISH TO RECEIVE THIS INFORMATION. YOU HAVE THE RIGHT TO REQUEST ACCESS TO, AND RECTIFICATION OF, YOUR PERSONAL DATA HELD BY US BY DIRECTING YOUR REQUEST TO OUR OFFICES.
ABOVE AND HEREBY CONSENT TO THE ABOVE TREATMENT OF MY PERSONAL DATA.
