Freelancers’ Accident Insurance Claim Form

Personal Information

Full Name

Date of Birth

Address

Email

Phone Number

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Accident Details

Date of Accident Location of Accident Describe How the Accident Occurred Injuries Sustained

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Medical Information

Name of Attending Physician Hospital or Clinic Name Treatment Received

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Employment & Insurance Details

Type of Freelance Work Policy Number Have you previously submitted a claim for this accident? Yes No

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Declaration

I hereby declare that the information provided above is true and correct to the best of my knowledge.

Signature

Date