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NOTIFICATION OF CLAIM FOR ACCIDENT AND DISEASES  


Our aim is not only to pay your claims but also to protect and assist you. For this purpose, it is indispensable that
you collaborate with us right now when completing this form. It is necessary that great care should be taken in supplying
the information set out below and the statements given should be strictly accurate, irrespective of whether the facts are in
your favour or otherwise.

You should not make any payment offer or promise of any payment or admit liability in any way, as by so doing
you may prejudice your position and make settlement a difficult matter.
If you have received any communications, verbal or written, please inform us forwarding all letters, etc, without
replying thereto. Please note that the issue of this form is not an admission of liability on the part of the Corporation.

With regard's
Ethiopian Insurance Corporation

TO BE FILLED BY THE EMPLOYER
THIS FORM MUST BE COMPLEED AND RETURNED WITHIN SEVEN DAYS OF THE ACCIDENT OR DISEASE
 
Branch claim to be submitted.
Employer
Town
Tel.
P.O.Box.
Higher
Kebele
Activity
Policy No.
Name-of the injured person (in full)
   
Date of birth
Registration No.
In the insured's service from
Date of the accident
Place of the accident
When was the employer informed of the accident?
 
Brief description of the accident
 
           
Daily wage birr (Birr    
Monthly Salary (Birr (the Imployer)
    Date:  
Witnesses
 
   
     
  Detachable slip for hospital; File No
     
  ETHIOPIAN INSURANCE CORPORATION BRANCH
To
Patient's name (in full)
Hospital.
Employer's Name
Address
You are kindly requested to assist the bearer of this form and offer him/her medical treatment and/or hospitalization if necessary.
your bill will be settled upon presentation.
N.B. this form is valid only when it bears the employer's seal and signature, and may only be used to authorize treatment and/or
hospitalization in case of accident or occupational disease.
Please attach a copy of this slip with your bill
 
Date
Employer's Signature(full name)