Small Business Insurance Claim Form

Policy Type*

Policy Holder Details

Policy Number

First Name*

Last Name*

ID Number*

Email Address*

Enter Email Confirm Email

Contact Phone Number*

Accident Details

Date of Accident*

Time of Accident

:

Location of Accident*

Police/Warden's Report Number (if applicable)

Brief description of claim*

Injured Persons

Name	Nature of Injury	Actions

There are no Persons.

Photos of Damages & Documents

Drop files here or

Max. file size: 5 MB.

If for any reason, including size of documents (should not exceed 5MB in size), they cannot be uploaded, you can send them through email on info@mib.com.mt.

Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

Small Business Insurance Claim Form

Policy Holder Details

Accident Details

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