NICL National Insurance Company Limited
Sign Up For Our Newsletter Unsubscribe
 
 
 
 
   
 
Client Name
Tel
Fax
Email
Policy No.
Name of claimant
Full residential/ postal address
Plan selected
Purpose of travel
Date of arrival
Date of departure
No. of days stayed
Name & address of govt. agency hosting you.
Date & time of accident
Date :
Time :  
Exact location
Nature of injury / sickness
Cause of injury
Were the Police notified
Contact details of the hospital or doctor whom you visited
Nature of treatment received
For how many days were you Hospitalized
Total medical cost so far incurred
Do you anticipate more expenses, if so?
Please specify
  I declare that all statements made on this form are true to the best of my knowledge and belief and that the articles and property described belong to the persons named, no other person having any interest therein, whether as Owner, Mortgagee, Trustee or otherwise.