INERCA · Workers’ Compensation claim

Workers’ Compensation claim form.

Complete and submit promptly. Forms A, B and C must accompany this claim. Fields marked * are required.

1. Policy & Contact Information

Policy Number *

Broker / Agent

Your Name *

Contact Number *

Email Address *

2. Injured Person

Name *

Job Title *

Job Description

3. Accident Details

Date & Time of Accident *

Where Did the Accident Occur? *

How Did the Accident Occur? *

Nature of Injury *

Steps Taken to Prevent Recurrence

4. Declaration & Consent

I declare that the information provided above is true, complete, and accurate to the best of my knowledge. I consent to Hollard collecting and processing my personal data to assess and process this claim in accordance with the Data Protection Act. I understand my data may be shared with third parties involved in processing this claim (assessors, repairers, reinsurers, etc.).

You can read Hollard’s full Data Privacy Statement at hollard.co.bw/…/hollard-privacy.

Submitting sends your claim to INERCA. We act for you, so we review it and lodge it with Hollard — you don’t need to contact Hollard yourself.

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INERCA Refined Insurance Solutions · licensed insurance agent, NBFIRA 2/10/686. We act for you with Hollard and Westlife; the insurer decides the claim.

Stuck? Call +267 78 607 912 or message us on WhatsApp.