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Imperial General Assurance
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Women’s Compensation Claim Form
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Full Name
*
First
Last
Address
Occupation
Job Description
Age
Marital Status
Amount of Weekly Earnings
How long has he/she been in your Employment?
Place of Accident
State the work the workman was engaged in at the time of the accident.
Was the injured worker under the influence of alcohol or any drug?
YES
NO
Date on which injured worker ceased work consequent upon the accident.
Please give a full description of how the accident happened
Please state the exact nature of injuries sustained by the worker.
Was the accident caused by the negligence of the injured worker or his/her co-worker? YES/NO, If yes, Please explain.
Name and address of witness.
I/We declare that the above statement is true in all respects to the best of my/our knowledge and belief and I undertake to give all information and assistance as the company may require.
Name and Signature of Policyholder.
Submit
Home
About Us
Company History
Board of Directors
Executive Management
Other Key Staff
Our Products
Branch Offices
Claims
Motor Vehicles Accident Report Form
Workmen’s Compensation Claim Form
Goods-In-Transit Claim Form
Bankers Indemnity/Fidelity Gurantee Claim Form
Gallery
News
Contact Us
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