Women’s Compensation Claim Form – Imperial General Assurance

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?

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.