Accidents and Diseases Claims Notification Form

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Disease To illness Claims Notification Form

Employer *

Address

Tel No. *

Woreda

P.O.Box

Policy No(where branch the policy issued)

Activity

Name of the injured person (in full) *

Date of birth

Category of work

Registration NO. In the insured’s service from

Date of accident *

Place of accident *

When was the Employer informed of the accident? *

Hours

Minutes

Brief description of the accident

Daily wage Birr *

Monthly Salary Birr *

The Employer Witnesses

Name of employer *

Date *

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