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Signature OfficerDate I I

Claim Form (Personal Accident Insurance)For Assumption university Officer

(Please fill in detail in claim form all item. If have no information, please cross out)

1. Name - Last Name of the insured Age yearsID No Faculty Class Year .

Current Address ....... ..Telephone No .

2. Date of accident occur ./ / at.. am./pm. Place of accident .

At that time, what are you doing? .

What is the cause of accident? .Symptom of InjUry Which organ .Name of eyewitness Telephone .o No 0 Yes Inform the police, at Date /. ./ .

In case of road accident, please specify the registration No. ofcar or motorcycle .

Had treatment in the hospital name Telephone .3. This injury you 0 have 0 no have right to compensate from other company/organization or not? If yes, please specify

4. I would like to claim for the amount of Baht foro Medical Expenses ( ) first time ( ) follow up 0 Dismemberment 0 Disability

o Loss of Life from Accident 0 Loss of Life from Health

I would like the company to pay cheque on the name of or transfer to deposit account(please attach the copy of book account which have account no.)

Account Name (The insured) Account No .Bank's Name Branch Type of account. .

And attach document for claim as follow:o Original receipt total copy 0 Original doctor's report total copyo Summarize the list of medical expenses total copy 0 X-ray film or result total. copy

o Police's report t9t.a~ copy 0 Copy ID card of the insuredo Copy census of the insured 0 Copy ID Card of the beneficiaryo Copy census of the beneficiary 0 Perform autopsy 0 Death certificate

o Other document .

* Remark: 1. In case broken bone or bone fracture, please send result from x-ray film to the company.

2. In case have lawsuit, please send result from police station to the company.

I certify that all detail above is correct. If the company find that the detail is not true, false or hide the truth, thecompany have the right to refuse or refund any claim. I agree to give my physician or hospital declare the fact ofsymptom and health record to Muang Thai Insurance PCL.

Signature Person inform and give the information

Status 0 The Insured 0 Parent 0 Officer 0 Attorney

Remark: If you receive the compensation delay more than 20 days, please contact P.A. claims department atTel: 0-2665-4070-71

Claims for Medical Expenses from AccidentEvidence1. Claim form (Personal Accident Insurance) which fill in all detail completely.2. Medical evidence such as doctor's report, result of treatment or result of x-ray film.3. Original receipt of medical expenses.4. In case assault have to attach police's report which informed on the date of accident or immediately.5. Send the claim form and other evidences to the officer of the university.

Remark1. Copy of receipt can not use to claims medical expenses. In case use receipt slip, please attach the summary of

medical expenses from the hospital.2. End of coverage:

2.1 Date as specified in the policy or.2.2 End date of the status of student or officer.

3. In case Loss of Life, please attach 2 sets of all evidences as follow (please sign "correct copy" all page) :3.1 Copy of ID Card and census of the insured, father and mother (In case the insured is minor, please attach

birth certificate).3.2 Perform autopsy from forensic laboratory.3.3 Police's report.3.4 Death certificate3.5 Change name certificate of the insured, father or mother (if any).3.6 Other document for considering claim in case the company need.

(The company reserve the right to inform later).