HEALTHCARE ONLINE CLAIM FORM

NOTE: PLEASE DO NOT NAVIGATE AWAY FROM THIS PAGE BEFORE COMPLETING THIS FORM.

(Please note that this form is issued without admission of liability.
Please state all relevant information requested as completely and as accurately as possible.)

Please provide the following details:
(*) Required information

INSURED'S PARTICULARS

Policy Number: *

Surname: *

Given Name: *

Date of Birth (DDMMYYYY): *

Sex: *

Male Female

Nationality: *

NRIC / Passport Number: *

Occupation:

Contact Number (H/O):

Mobile Number:

Address: *

Country: *

Email Address: *

Are you submitting a claim under a company group policy? *

Yes No

EMPLOYEE'S PARTICULARS (IF APPLICABLE)

Name of Employee: *

Nationality: *

Date of Birth (DDMMYYYY): *

NRIC / Passport Number: *

Relationship to Employee (if applicable):

Date of Employment (DDMMYYYY): *

Eligibility for Benefits (Eg. Plan A, Standard/Platinum):

Occupation: *

EMPLOYER'S PARTICULARS (IF APPLICABLE)

Name of Employer: *

Country: *

Address: *

Postal Code: *

HR Email address of your Employer:

CLAIMANT’S PARTICULARS

Name of Claimant: *

Date of Birth (DDMMYYYY): *

NRIC / Passport Number:

Relationship to Policyholder / Employee:

Occupation:

Please select the section relevant to your particular claim:

(A) FOR INJURY CASES


Date of Accident (DDMMYYYY): *		Time of Accident (HHMM): *

Where did it occur?

How did the accident happen? *

Nature and Extent of injuries you sustained? *

Is this a job-related accident? *		Yes No

Are you covered under any other policy for reimbursement of medical expenses? *		Yes No

Attending Doctor's Name: *

Attending Doctor's Address: *

Has the claimant previously suffered from an injury to the same part? *		Yes No

If yes, please give details

(B) FOR ILLNESS

Nature of illness / Final Diagnosis: *

Date symptoms first started (DDMMYYYY):

Date first treated (DDMMYYYY):

Attending Doctor's Name: *

Attending Doctor's Address: *

Has the illness been treated previously? *		Yes No

If yes, state the name & address of physician and when you knew about this problem?

Are you entitled to claim against any other medical expenses insurance? *		Yes No

Is the sickness due to pregnancy, abortion, miscarriage, sterilization or infertility? *		Yes No

If yes, please specify condition

Is this condition arising from employment?		Yes No

ATTACHMENT

Please attach required supporting documents below. For list of Supporting Documents, please click here.
Note: Medical Claims must be supported with original receipts. Attachments must be in GIF, JPG, JPEG, PDF or PNG format and less than 10 MB in total size.

File Name	Size	Action

MODE OF PAYMENT

My preferred way to receive payment is

Please confirm that your PayNow is registered with NRIC/FIN?

PayNow Details

Please ensure you have registered for PayNow with your NRIC/FIN with one of the participating banks: https://www.abs.org.sg/consumer-banking/pay-now If you have not registered for PayNow with your NRIC/FIN, please choose a different payment method to receive your payment.

Name of Account Holder: *

NRIC/FIN: *

We will make the payment via other modes if your preferred payment mode is unavailable or not possible.

Bank Details

Account Holder: *

Bank Name: *

Account No: *		Please key in numbers only and omit any dashes '-'.

We will make the payment via other modes if your preferred payment mode is unavailable or not possible.

To receive your payment faster, please select either "PayNow" or "Credit to my bank account"

Name of Payee: *

DECLARATION

Please note that you are submitting this claim to MSIG Insurance (Singapore) Pte Ltd. Please see our full Terms of Use and Privacy & Cookies Policy.

By submitting this claim to us, you are deemed to have agreed to us collecting, using, disclosing and processing your personal data for the purpose of assessing your claim. This may include disclosing and sharing your personal data with our service providers and/or with other insurers in the general insurance industry, including the General Insurance Association of Singapore, for the proper processing, handling and/or dealing with your claim, which includes investigating the said claim, and complying with applicable laws (collectively, 'the Purpose'). We may also need to disclose or share your personal data with service providers who are sited outside Singapore for the Purpose.

I declare that the information given is true and correct to the best of my knowledge and belief. I understand that any false or fraudulent statements or any attempt to suppress or conceal any material facts shall render the policy void and the Insurer may refuse to pay the claim.

Name of Policyholder: *

NRIC / Passport Number: *

Name of Claimant: *

NRIC / Passport Number: *

Date (DDMMYYYY): *

Verification Code: *		Please enter Verification Code as shown below



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