Child Personal Accident Insurance Claim Form
1. Policy Details
Policy Number
Insurer's Name
2. Child’s Information
Full Name
Date of Birth
Gender
Male
Female
3. Parent/Guardian Information
Name
Relationship to Child
Contact Number
Email
Address
4. Accident Details
Date of Accident
Time of Accident
Place of Accident
Describe How the Accident Occurred
Nature of Injury
Treated by (Doctor/Hospital)
5. Claim Details
Total Amount Claimed
Details of Expenses Incurred
6. Declaration
I declare that the information given above is true and complete to the best of my knowledge.
Name
Date
Signature