Domestic Worker Accident Insurance Claim Form
Policy Holder Details
Full Name
Policy Number
Address
Contact Number
Domestic Worker Details
Full Name
Nationality
Identification Number
Contact Number
Accident Details
Date of Accident
Time of Accident
Location of Accident
Description of Accident
Witness Name
Witness Contact
Medical Attention
Was medical attention required?
Yes
No
Name of Hospital/Clinic
Details of Injuries
Declaration
Name of Declarant
Date
Signature