Personal Accident & Sickness Claims Notification Form

You will be contacted by a claims handler in due course, who will advise you of the claim reference number and any further documentation that is required in support of your claim.

When you submit this form you will be sent an acknowledgement email. Attached to the email will be a form giving Allianz consent to obtain a medical report from your doctor. Please complete, sign and return to:

Barclays Business Insurance Claims Centre 500 Avebury Boulevard, Milton Keynes MK9 2XX

Please note that fields marked with asterisk (*) are mandatory.

Policyholder Details

Policy Number Prefix*

Policy Number (e.g. PX 123456)*

Help tip: Select to choose a prefix. Policy Number must not contain letters.

Title*

Forename*

Surname *

Address 1 *

Address 2

Address 3

City*

County *

Postcode, including spaces *

Telephone*

Email*

Insured Person Details

Are the Insured Person details the same as the Policyholder?*

Name*

Insured Person Address 1 *

Insured Person Address 2

Insured Person Address 3

City*

County*

Postcode, including spaces*

Telephone *

Occupation

Date of Birth*

Day Month Year

Date first absent from work*

Day Month Year

Duties carried out

Annual salary or gross basic Weekly wage

Are you totally disabled from working?*

When does your doctor say you will be fit to resume work?

Day Month Year

Name & Address of doctor who signed medical certificate *

Name & Address of usual doctor if different from above

Sickness Claim

What is the nature of sickness

Period of sickness from

Day Month Year

Period of sickness to

Day Month Year

Is the sickness still ongoing?

Please advise the date you anticipate you will return to full fitness

Day Month Year

Have you ever suffered before from the same sickness?

State when

Day Month Year

How long you were off work

Accident Claim

Date of Accident

Day Month Year

Time of Accident(hour)

Time of Accident(minute)

Accident location

Full details and description of the accident

Nature and extent of injury/disability

Have you had a similar accident before?

Details of similar accident

Are you claiming under or being paid any benefit by any other insurance or sources in respect of this disablement?

State name and address of insurer, policy number and benefits

Terms & Conditions

Please read and confirm acceptance of Allianz Terms & Conditions*

I accept Allianz terms and conditions

Allianz Insurance plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 121849

Personal Accident & Sickness Claims Notification Form

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