FSA Business Portal
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Request Form For Help From Injury Assistance Guarantee Fund
Personal Information
Applicant Name
Description of Applicant
Select
Self Representative
Under-Heirs
Other
The Other Characteristic
Identity Type
Select
Id Card
Resident Card
Passport
Driving Licence
Other
Identity Number
Contact Info
Mobile Phone
(
+
968)
Alternative Phone Number
Email
*
Details
Accident Date
Accident Type
*
Select
Simple (Material Damage Only)
Terrible (Bodily and Material Damage)
Damage Type
*
Select
Material
Bodily
Both
Vehicle Condition
*
Select
Cancelled
Damaged
Does Not Apply
Case Details
Demands
Approximate Damage Cost
Documents
#
Document Type
Upload File
1
Accident Report of ROP (Final)
*
2
Legal Agency
*
3
Offender Vehicle Ownership (if any)
4
Victim Vehicle Ownership
Accident Parties
You can select multiple documents for the Treatment bills.
#
Full Name
Identity Number
Situation Type
Documents
1
*
*
*
Select
Injured
Inability
Death
Id Card
*
Treatment Bills
*
Medical Report
*
Death Certificate
*
Declaration
Disclaimer
Submitting the application doesn’t mean final admission. FSA may reject the application.
Injured person compensation fund covers only third party insurance policyholders.
Injured persons compensation fund covers only the traffic accidents from 15 April, 2018.
Pledge and Commitment
I, the applicant , hereby declare all the attached statements and documents are correct, otherwise the competent entity may take all the required actions. I also subrogate the fund all the rights and to take all legal actions including instituting proceedings including granting a power of attorney to whoever it sees fit or law firms to sue the driver or owner of the vehicle that caused the accident where the vehicle or owner or driver is identified
Agree
To apply, damage cost must be 500 OMR at least
Fields marked with an asterisk (
*
) must be filled
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