NICL National Insurance Company Limited
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Client Name   
Tel
Fax
Email  
Policy No.    
Name of claimant    
Full residential / postal address    
Plan selected    
Purpose of travel    
Date of arrival    
Date of departure    
No. of days stayed  
Name & address of govt. agency hosting you    
Date & time of accident
Date:    
Time:    
Exact location    
Nature of injury / sickness    
Cause of injury    
Were the Police notified    
Contact details of the hospital or doctor whom you visited    
Nature of treatment received    
For how many days were you Hospitalized  
Total medical cost so far incurred    
Do you anticipate more expenses, if so?    
Please specify    
Please Enter Text