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Accident Claim Form

Accident Claim Form Template for Indonesia

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Key Requirements PROMPT example:

Accident Claim Form

"I need an Accident Claim Form in Indonesian and English for our manufacturing company's insurance policy compliance, specifically designed for workplace accidents with emphasis on machinery-related incidents and automated reporting capabilities."

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Document background
The Accident Claim Form is a crucial document used in the Indonesian insurance sector for initiating and processing claims related to various types of accidents. This document is designed in accordance with Indonesian insurance regulations, particularly Law No. 40 of 2014 on Insurance and OJK guidelines, and serves as the primary mechanism for individuals and organizations to file accident-related insurance claims. The form collects comprehensive information about the accident, including claimant details, accident circumstances, injuries or damages sustained, witness statements, and medical information. It is used across various scenarios including personal accidents, workplace incidents, and vehicle-related accidents, and requires supporting documentation such as medical reports, police reports, and photographic evidence to substantiate the claim.
Suggested Sections

1. Claimant Information: Personal details of the person making the claim, including full name, ID number (KTP), contact information, and policy number

2. Accident Details: Comprehensive information about when, where, and how the accident occurred, including date, time, location, and description of the incident

3. Injury/Damage Description: Detailed description of injuries sustained or property damage incurred as a result of the accident

4. Medical Treatment Information: Details of any medical treatment received, including healthcare providers, dates of treatment, and diagnosis

5. Witness Information: Contact details and statements from any witnesses to the accident

6. Police Report Details: Information regarding police reports filed, including report number and issuing police station

7. Claim Amount: Specification of the amount being claimed and breakdown of costs

8. Declaration and Authorization: Claimant's declaration of truth and authorization for the insurance company to access relevant records

Optional Sections

1. Vehicle Details: For motor vehicle accidents - details of all vehicles involved including registration numbers, insurance details

2. Workplace Accident Details: For workplace accidents - employer information, work activity being performed, and workplace safety measures

3. Third Party Information: When third parties are involved - their personal details and insurance information

4. Property Damage Details: For accidents involving property damage - detailed description of damaged property and ownership information

5. Previous Claims History: If required by insurer - details of any previous insurance claims made by the claimant

Suggested Schedules

1. Schedule A - Medical Expense Details: Itemized list of medical expenses with supporting documentation

2. Schedule B - Property Damage Assessment: Detailed assessment of property damage including repair estimates or invoices

3. Schedule C - Supporting Documents Checklist: Checklist of required supporting documents including medical reports, police reports, photographs

4. Schedule D - Witness Statement Form: Standardized form for recording detailed witness statements

5. Appendix 1 - Medical Authorization Form: Standard form for authorizing release of medical records

6. Appendix 2 - Photo Documentation: Format for submitting photographic evidence of injuries or damage

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok成人版 | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions




































Clauses

























Relevant Industries

Insurance

Healthcare

Legal Services

Transportation

Manufacturing

Construction

Retail

Hospitality

Education

Mining

Oil and Gas

Public Sector

Maritime

Relevant Teams

Legal

Human Resources

Risk Management

Compliance

Insurance Operations

Claims Processing

Customer Service

Documentation

Health and Safety

Administrative Support

Relevant Roles

Insurance Claims Officer

Risk Manager

Compliance Officer

Legal Counsel

Human Resources Manager

Safety Officer

Insurance Underwriter

Claims Adjuster

Insurance Agent

Medical Claims Processor

Corporate Safety Director

Employee Relations Manager

Insurance Operations Manager

Legal Administrator

Risk Assessment Specialist

Industries







Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks, 聽Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination, 聽Severance Pay, Governing Law, Entire Agreemen

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