Consumer Credit Insurance Claim Form - Avea Insurance
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4Consumer Credit Insurance
-Claim Form-
INSTRUCTIONS ON HOW TO COMPLETE YOUR CONSUMER CREDIT INSURANCE CLAIM FORM
You must answer ALL questions. Where indicated please tick box as applicable.
If you have had an ILLNESS
complete Sections 1, 2, 3, 5 & 7
If you have had an ACCIDENT
complete Sections 1, 2, 4, 5 & 7
If you have been UNEMPLOYED complete Sections 1, 6 & 7
Policy No.
Period of Insurance: From
/
/
to
/
/
SECTION 1: GENERAL INFORMATION
Full Name of Insured: Surname:
Given Names:
Date of Birth:
/
/
Private Address:
Postal Address:
Name of Employer:
Occupation:
Telephone: Private:
Business:
Email:
Finance Company:
Finance Contract No.
Amount of Monthly Payment:
Outstanding Balance:
Date Payment Due:
SECTION 2: GENERAL MEDICAL INFORMATION
Date of first examination or treatment by medical attendant for this occurrence:
/
/
Name and Address of doctor who first attended you:
Name and Address of usual medical attendant:
Name and Address of the medical attendant now treating you:
Name and Address of other medical attendants for any accident or illness in the last 5 years:
Have you engaged in or attended to your usual profession, business or occupation since the date of accident or the date upon which the illness became evident (even if only
in a reduced capacity)?
YES
NO
State dates between which you were confined:
To Bed:
From:
/
/
To:
/
/
To House:
From:
/
/
To:
/
/
SECTION 3: ILLNESS
What is the nature of the illness?
When did it first become evident?
Have you ever suffered from or sought treatment for the illness in respect of which you are now claiming?
YES
NO
If YES, give details including date you last sought treatment:
Period for which you are claiming:
From:
/
/
To:
/
/
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