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[]
[]
[{"$nulls":7},"CLAIMANT'S STATEMENT FOR ACCIDENT & SICKNESS BENEFITS"]
[{"$nulls":7},"THE INSURED IS RESPONSIBLE FOR THE COMPLETION OF THIS FORM WITHOUT EXPENSE TO THE COMPANY"]
[]
["PART A - COMPLETE IN FULL"]
[]
["1.  Full Name (Please Print)",{"$nulls":7},"9.  Give date and hour when accident occurred (or beginning date of illness if disability claim)."]
[]
["2.  Certificate Number",{"$nulls":4},"3.  Age",null,null,"Day",null,null,"Month",null,null,"Year"]
[]
["4. Height",{"$nulls":4},"5.  Weight",{"$nulls":5},"at ",null,null,"o'clock"]
[]
["6. Residential Address",{"$nulls":7},"10.  On what day did you stop performing all your occupational duties?"]
[{"$nulls":8},"Day",null,null,"Month",null,null,"Year"]
["ID #",{"$nulls":4},"Tel #"]
["7.  Employer's Address",{"$nulls":7},"11.  Have you done any work since commencement of disability? If yes, please explain."]
["No.",null,null,"Street"]
["City",{"$nulls":4},"Country"]
["Employer ",{"$nulls":7},"12. How do you spend your time?"]
["Nature of Business"]
[{"$nulls":8},"13.  Confined to house from ",{"$nulls":4},"to"]
["8.  Occupation",{"$nulls":3},"8a.  Average earnings per week"]
[{"$nulls":8},"14.  Confined to hospital from ",{"$nulls":4},"to"]
[]
["8b.  Describe Duties",{"$nulls":7},"15.  When do expect to return to work?"]
[{"$nulls":8},"Day",null,null,"Month",null,null,"Year"]
[]
["16.  Give date consulted and Name and Address of every Physician consulted by you on account of present condition:"]
[null,"Day","Month","Year",null,"Name",{"$nulls":5},"Address"]
[]
[]
[]
[]
["PART B - COMPLETE FOR ACCIDENT CLAIM ONLY",{"$nulls":7},"PART C - COMPLETE FOR SICKNESS CLAIM ONLY"]
["A.  What bodily injury did you sustain wholly by the accident?",{"$nulls":7},"A.  Describe fully your present condition"]
[]
[]
["B. Where and how did the accident occur?",{"$nulls":7},"B.  Has any member of your family been afflicted with a similar disease?"]
[]
["C.  If partial disability is claimed, state the particular duties you were unable to ",{"$nulls":7},"C.  Have you seen a physician within the last three (3) years for reasons other than your "]
["perform during the entire period of partial disability.",{"$nulls":7},"present condition?  If yes, give reasons, date, name and address of physician."]
[]
[]
["D.  Were you on vacation or unemployed during any period of disability?"]
[]
["E.  Has disability resulting from accident ended and is this your full claim?"]
[{"$nulls":8},"NOTE: This blank form is furnished to the insured without prejudice to or waiver of any right of defense that the Company may have relative to any claim filed hereunder."]
["F.  How long were you totally disabled? ",{"$nulls":4},"weeks",null,"(days)"]
["G.  How long were you partially disabled?",{"$nulls":4},"weeks",null,"(days)"]
[]
[]
["NB. All expenses must be supported by detailed bills. Only original bills are acceptable. Hospital Bills should state the number of days spent and the charge for each day as well as itemized charges for other hospital services; drug bills should show the date of purchase, prescription number, name of patient, name of doctor, name or type of drug and costs.  Bill for x-rays should show the date, patient's name, and the charges.  \n\nThe foregoing statements are full and true to the best of my knowledge and belief, and I agree that payment according to the terms of the policy, for the period of disability as herein indicated, should be in full satisfaction and discharge of any and all claims, the cause of which originated prior to the date hereof."]
["I hereby authorise: a) any physician, hospital, clinic, insurance company, or other organisation, or person that has any records or knowledge of my family or me, to give to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates any and all information about my family members or me with reference to our finances, our health and medical history and any hospitalization, advice, diagnosis, treatment, disease or ailment.  b) Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates to provide the information derived from this application and any other existing record, to service providers and related third parties in order to evaluate any insurance proposal request made by me and for the purposes of administration of this policy. c) the disclosure of all information necessary to process this claim to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. affiliates wheresoever located including but not limited to the United States of America and Panama and to such other parties as may reasonably be required to process this claim."]
["A photographic copy of this authorization shall be as valid as the original."]
{"$rows_empty":10}
[".10/16"]
[]
["ATTENDING PHYSICIAN'S STATEMENT\nACCIDENT AND SICKNESS\nTHE INSURED IS RESPONSIBLE FOR THE COMPLETION OF THIS FORM WITHOUT EXPENSE TO THE COMPANY"]
["Patient's Name (please print)",{"$nulls":7},"Age"]
["1.  Nature of sickness or injury.  (Describe complications, if any)"]
[]
[]
[]
[]
["2.  Is condition due to pregnancy?",{"$nulls":7},"Yes","o",null,null,"No","o"]
[]
["3.  If yes, what was the approximate date of commencement of pregnancy?",{"$nulls":7},"Date:","Day",null,null,"Month",null,null,"Year"]
[]
["4.  If fracture or dislocation, state whether complete or incomplete.",{"$nulls":7},"Complete","o",null,null,"Incomplete","o"]
[]
["5.  If fracture of long bones, state whether fracture is through shaft or extremity.",{"$nulls":7},"Shaft","o",null,null,"Extremity","o"]
[]
["6.  Was it confirmed by x-ray?",{"$nulls":7},"Yes","o",null,null,"No","o"]
[]
["7. When did symptoms first appear or accident happen?",{"$nulls":7},"Date:","Day",null,null,"Month",null,null,"Year"]
[]
["8.  When did patient first consult you for this condition?",{"$nulls":7},"Date:","Day",null,null,"Month",null,null,"Year"]
[]
["9.  Has patient ever had same or similar condition? If yes, state when and describe.",{"$nulls":7},"Yes","o",null,null,"No","o"]
[]
["10.  Describe any other disease or family infirmity affecting present condition."]
[]
["11.  Nature of surgical or obstetrical procedure if any (describe fully)"]
[]
["12.  Give dates of treatment",{"$nulls":11},"Charge per call"]
[{"$nulls":8},"Office",{"$nulls":3},"$"]
[{"$nulls":8},"Home",{"$nulls":3},"$"]
[{"$nulls":8},"Hospital",{"$nulls":3},"$"]
[]
["13.  Is patient still under your care for this condition? If discharged, give date.",{"$nulls":7},"Yes","o",null,null,"No","o"]
[{"$nulls":8},"Date discharged"]
[]
["14.  If patient hospitalized, give name and address of hospital.",{"$nulls":7},"Hospital"]
[{"$nulls":8},"City",{"$nulls":3},"State",null,"Country"]
[{"$nulls":8},"Date admitted:",{"$nulls":3},"Date discharged:"]
[]
["15.  How long was patient totally disabled (unable to work)?",{"$nulls":7},"From",{"$nulls":3},"Through"]
[]
["16.  If sickness, was patient confined to the house?  If yes, give dates.",{"$nulls":7},"Yes","o",null,null,"No","o"]
[{"$nulls":8},"From",{"$nulls":3},"Through"]
[]
["17.  Is condition due to injury or sickness arising out of patient's employment?\n       If yes, explain.",{"$nulls":7},"Yes","o",null,null,"No","o"]
[]
["REMARKS:"]
[]
[]
["I HEREBY CERTIFY THAT MY ANSWERS TO THE FOREGOING QUESTIONS ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF."]
[]
[]
[]
["Date:",{"$nulls":7},"Signature:"]
[{"$nulls":10},"Physician or Surgeon"]
[]
[]
[{"$nulls":10},"Office Address"]
{"$rows_empty":11}
[".10/16"]