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Personal Accident Claim Form

Personal Accident Claim Form Template for Indonesia

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Personal Accident Claim Form

"I need a Personal Accident Claim Form for our Indonesia-based manufacturing company that complies with OJK regulations, includes bilingual Indonesian-English text, and has specific sections for workplace accidents with multiple witness statements."

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Document background
The Personal Accident Claim Form is a crucial document used in the Indonesian insurance industry for processing claims related to accidental injuries or death. This form is designed in accordance with Indonesian insurance regulations, particularly Law No. 40 of 2014 on Insurance and OJK guidelines. It is utilized when an insured individual needs to make a claim following a personal accident, requiring detailed information about the accident circumstances, medical treatment received, and financial impact. The form serves as the primary document for initiating the claims process, collecting essential information needed for claim assessment, and ensuring compliance with regulatory requirements for insurance claim processing in Indonesia. It includes sections for medical authorization, privacy consent, and declaration of truth, as mandated by Indonesian law.
Suggested Sections

1. Personal Information: Claimant's details including full name, ID number (KTP), date of birth, address, contact information, and occupation

2. Policy Details: Insurance policy number, type of coverage, period of insurance, and sum insured

3. Accident Details: Date, time, and location of accident, detailed description of how the accident occurred

4. Injury Details: Nature and extent of injuries sustained, affected body parts, and current condition

5. Medical Treatment Information: Details of medical facilities visited, dates of treatment, attending physician's information

6. Employment Status Impact: Information about work absence, disability period, and impact on employment

7. Other Insurance Coverage: Declaration of other relevant insurance policies or claims

8. Bank Account Details: Beneficiary's bank information for claim payment transfer

9. Declaration and Authorization: Claimant's declaration of truth and authorization for medical information release

Optional Sections

1. Witness Information: Contact details and statements from witnesses, if any were present during the accident

2. Police Report Details: Required when accident involves criminal act, traffic accident, or requires police intervention

3. Employer's Statement: Required for work-related accidents or when claim involves loss of income

4. Guardian Information: Required when claimant is a minor or mentally incapacitated

5. Third Party Involvement: Details of any third parties involved in the accident, including their insurance information

Suggested Schedules

1. Required Documents Checklist: List of mandatory supporting documents to be submitted with claim form

2. Medical Report Form: Standard form to be completed by attending physician

3. Accident Scene Photographs: Guidelines for submitting photographic evidence of accident scene if applicable

4. Income Loss Calculation Sheet: Template for calculating loss of income claims

5. Medical Expense Summary: Template for itemizing medical expenses related to the accident

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

Financial Services

Legal Services

Risk Management

Employee Benefits

Corporate Services

Human Resources

Medical Services

Claims Management

Relevant Teams

Claims Processing

Underwriting

Legal

Compliance

Customer Service

Risk Assessment

Medical Assessment

Policy Administration

Claims Investigation

Operations

Relevant Roles

Claims Manager

Insurance Underwriter

Claims Adjuster

Risk Assessment Officer

Insurance Agent

Claims Processing Specialist

Compliance Officer

Legal Counsel

Medical Claims Assessor

Customer Service Representative

Benefits Administrator

Insurance Operations Manager

Policy Administration Officer

Claims Investigation Officer

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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