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NOTE: PLEASE DO NOT NAVIGATE AWAY FROM THIS PAGE BEFORE COMPLETING THIS
FORM.
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(Please note that this form is issued without admission of
liability.
Please state all relevant information requested as completely and as accurately
as possible.) |
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Please provide the following details:
(*) Required information |
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INSURED'S PARTICULARS
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Policy Number: * |
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Surname: * |
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Given Name: * |
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Date of Birth (DDMMYYYY): * |
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Sex: * |
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Male
Female
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Nationality: * |
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NRIC / Passport Number: * |
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Occupation: |
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Contact Number (H/O): |
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Mobile Number: |
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Address: * |
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Country: * |
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Email Address: * |
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Are you submitting a claim under a company group policy? * |
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Yes
No
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CLAIMANT’S PARTICULARS
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Name of Claimant: * |
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Date of Birth (DDMMYYYY): * |
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NRIC / Passport Number: |
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Relationship to Policyholder / Employee: |
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Occupation: |
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Please select the section relevant to your particular claim: |
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(A) FOR INJURY CASES
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(B) FOR ILLNESS
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ATTACHMENT
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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. |
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MODE OF PAYMENT
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My preferred way to receive payment is |
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Please confirm that your PayNow is registered with NRIC/FIN? |
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DECLARATION
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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.
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