QATAR INSURANCE COMPANY

WORKMEN COMPENSATION CLAIM ADVICE

(THE ISSUANCE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY)

Policy No.:
THE POLICY HOLDER:

Claim No.:

THE INJURED

1. Name: 3.Age: 6.Insurance List Nr.

THE ACCIDENT

2. Male/Female: 4. Nationality: 7. Salary Monthly /Daily 10. Date: 5. Occupation: 8.Work days per week: 11. Time: am/ pm

9. Place:

12. Circumstances and description of the accident:

13. Nature and extent of injury:

14. Whether the Police were informed of the accident? (If yes, please enclose Police Report.) 15. Name (s) and address of other person (s), if any, involved in the accident:

Yes No

16. Name (s) and address of witness (es):

Contd02

Page: 02 MEDICAL TREATMENT (Please enclose original medical certificate (s) stating details

of the injuries, treatment

and duration of sick leave, if any. recommended.) 17.Name and address of the doctor by whom treatment was given:

18. Has the injured person resumed duty?

Yes/No

19. Resumed duty on

20. Following documents in original hereto attached please tick () the appropriate 1. 2.

Medical Report and Sick leave Certificate (s) due to injury. A copy of document showing name and declared salary as evidence of inclusion of the employee for this Workmen Compensation Insurance with us [in case All Employees insured, please furnish a copy of the Pay Slip as on Date of Accident]. Police Report.[ In case of Road Traffic Accident, Traffic Police

3.

Accident Report and details of Motor Insurance Policy of the vehicles involved in the accident are required.]
4. 5. 6.

Medical Boards Report on Permanent Disability, if any. Directive from the Department of Labour/Ministry of Interior, for Permanent Disability.
For Death Cases only:-

(a) Death Certificate, Copy of Passport/ID/Visa. (b) Directive from Court asking the employer to pay compensation.
7.

Name of other relevant documents.

Date:

Office Name and Seal

Signature of the Insured

FOR OFFICE USE ONLY Computation of compensation payable:

P.O.Box 666, Doha, Qatar Telephone: (+974) 4962 222 Fax: (+974) 4831569