Injury / Illness Claim

No 2 The Colosseum Building
Century City  Boulevard

 Century City

PO Box 90 Century City 7446
Tel: (27) (21) 529 7800 
Fax: 0865 202 355
E-mail: insure@aib.co.za
 Insured
Name
Surname
Address
Telephone
Fax
E-mail
Policy Number
VAT Registration Number
 Insured Person
Name
Age
Business or occupation
 Relationship with insured person
If employee, give annual earnings as defined in the policy
If other, specify relationship
 Injury / Illness
When did the accident or illness commence
Where did the accident or illness commence
Give full particulars of the accident and nature of injuries, or the name of the illness
 Witness
Name and address of witness
 Doctor
Name of doctor who attended you
Address of doctor who attended you
Name of your usual doctor
Address of your usual doctor
 Disablement
Period of temporary total disablement
Period of temporary partial disablement
Date when normal occupation resumed
Has any permanent disablement resulted? If yes, give details
 Other Insurance
Give name of any other insurer with whom insured person is insured
 Previous Claims
Give details of all claims made against insurers or in terms of WCA by the insured person
 Authority for payment
It is recommended that any amount payable to you directly be transmitted by Electronic Bank Transfer for speedier settlement and security reasons.
Do you agree to this? Yes     No
 Signature
Name
Signature
Please print the completed form and fax the signed document to 0865 202 355
  
The second part of this form has to be completed by the doctor you consulted and can be faxed to us. Open form