Delivery Personnel Accident Insurance Claim Form
1. Personal Information
Full Name
Contact Number
Email Address
Address
Date of Birth
Employee/Personnel ID
2. Accident Details
Date of Accident
Time of Accident
Location of Accident
Describe the Accident
3. Injury & Medical Details
Nature of Injury
Treatment Received
Attending Doctor / Hospital
Medical Expenses (if any)
4. Additional Information
Other Relevant Details
5. Declaration
I declare that the information provided above is true and complete to the best of my knowledge.
Signature
Date