Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling in the Certificate Holder’s Details section. This includes entering the Certificate Number, Date of Birth, Full Name, Address, Post Code, and Telephone Number.
3. Next, complete the Patient’s Details section by providing their Full Name, Date of Birth, Relationship to the Certificate Holder, and their Address if it differs from the certificate holder’s.
4. In the Details of Accident section, document the Date and Time of the accident and provide a detailed description, including the location and circumstances surrounding the accident. If applicable, attach any police reports.
5. If the accident occurred in the context of employment, fill out the relevant employment details including the name and address of the employer and their telephone number.
6. In case the injury resulted from a road traffic accident or occurred overseas, provide the required insurance details including the name and contact information of the insurer.
7. In the Medical Treatment/Details section, provide details about the injury, including the hospital attended, details of the doctors treating the patient, dates of admission and discharge, and a summary of the treatment received.
8. Complete the Declaration and Authorisation section to confirm that the information provided is accurate and consent is given for medical information to be shared.
9. If needed, use the Additional Information section for any extra details that may assist in processing the claim.
10. Finally, review your responses, ensure all signatures are in place, and save your changes. You can then download, print, or share the completed form as necessary.

Complete your documentation online today to ensure a smooth claims process.