Pupil Personal Accident Report printable pdf download

Pupil Personal Accident Report

Pupil Personal Accident Report Form

Religious/Education Claims

BEFORE COMPLETING THIS FORM, PLEASE SEE INSTRUCTIONS BELOW. PLEASE USE BLOCK CAPITALS.

Instructions

1. The Pupil Personal Accident Policy only provides cover for medical and/or dental costs incurred as a result of an accident as defined

by the policy, where no other cover is in force, such as private health cover or medical card scheme.

2. This form should be completed, signed and dated by both the parent/guardian and the school principal.

3. The completed form should be returned to Allianz as soon as possible after the accident has occurred.

4. Please only attach original invoices/bills as we cannot pay your claim if you submit photocopy invoices/bills.

5. Note: Any claim will be handled in line with the cover granted by your policy.

6. Please ensure Section 8 Payment Details is completed in full.

1. School details

Policyholder’s name:

Address:

Email address:

Telephone number:

Policy number:

Is the injured pupil covered for school activities or 24 hour cover?:

School activities

24 hour cover

2. Injured pupil and parent’s/guardian’s details

Pupil’s name:

Age at time of incident:

Class name/year:

Parent’s/guardian’s name:

Parent’s/guardian’s address:

Parent’s/guardian’s

telephone number:

3. Accident circumstances and related particulars (to be completed by the school principal or parent/guardian as appropriate)

Date and time of accident:

am/pm

Please describe fully the location, circumstances and nature of the accident:

Please continue overleaf

Pupil Personal Accident Report