Workmen Compensation Claim Declaration Form

We are providing you with a Claim Form to fill in case you have to report any loss or damage covered under your policy.

In this Department, even though declaring the event should be made within 72 hours, after the Loss, this declaration could be made either by telephone or by fax to make it quick, but it is still necessary to fill in a Claim Declaration Form. For this reason, we are providing you with this form just to put you in the mood of what could we ask you about in terms of declaration thus relieving you from the move.

You should have to fill in the Claim Form provided in your policy to be submitted to the hospital.
Otherwise you should call us at the Company so we could arrange an acceptance with the hospital.

The following is the list of agreed network of hospitals:

Beirut: Saint Joseph Hospital - Dora Rosary Hospital - Gemmayzeh Hopital Libanais - Geitawi Najjar Hospital - Wardieh Trad Hospital - Clemenceau Sahel Hospital - Ghobeiry Makassed Hospital - Makassed SOUTH METN Sainte Thérèse Sacré - Coeur North Metn Haroun Hospital Serhal Hospital Abou Jaoudeh Hospital Keserwan Saint Louis Notre Dame du Liban Jbeil Jounieh Notre Dame Maritime Notre Dame du Secours Aley Al Iman Hemlin

North Mounla - Tripoli Nini - Tripoli Saydet Zghorta- Zghorta Complexe Hospitalier du Nord - Zghorta Bourji - Koura Chouf Ain wa Zein Baaklin Medical Center South Hammoud - Saida Labib Medical Center - Saida Al Najda Al Chaabia - Nabatieh Jabal Aamel - Tyre Bekaa Libano-Français - Zahlé Khoury - Zahlé Riyack - Riyack Dar el Amal - Baalbeck Farhat - Jib Jannine

PS: Fields marked with a (*) are required.
Policy Holder *
Address
E-mail *
Phone Number
Policy Number *
Address of Risk
Time and Date of Accident	HH:MM dd/MM/yy
Name of Injured Employee /Worker
His Occupation
His Nationality
His Age
His Salary
His Address
Name of Hospital
Was There any Expert Report	Yes No
Forensic / Expert Name
Brief Description / Cause of the Accident
Please state whether there was any witnesses

[ back to top ]