Group Personal Accident Claim Form Name of Insured(First) Last Name Policy Number Email Address* Address Street Address Address Line 1 City Date of Accident* Time Give a dull description of the Accident and where it happened and also what you were doing at the time* Give Name and Address of Witness State, as precisely as you can, what injuries you have sustained How long have you been confined to the Hospital /Your House? From Until If not confined to either, state the fact Describe the Totally ‘Disabled extent and Probable further duration of Disability (if any) Days from Total Disability To Have you been able since the Accident to give attention to any portion of your business or occupation? Yes No If so, to what extent and from what date? State if claiming or entitled to Compensation for Disablement from any other policy or Society. If so, give particulars. What are you now prepared to accept in full settlement of the claim? Days Total Disablement Days Partial Disablement Medical Report The Medical Report Form must in every case be filled in, and the questions FULLY answered and attached to the claim form I hereby certify that the information in this claim form is true and correct to the best of my knowledge and belief. I authorize Champions Insurance Company to process the claim based on the information provided.