PERSONAL LINES
PERSONAL ACCIDENT / MEDICAL 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: *  
     
Sex: *   Male   Female
     
Nationality: *  
     
NRIC/Passport Number: *  
     
Occupation:  
     
Contact Number (H/O):  
     
Mobile Number:  
     
Address: *  
     
Country: *  
     
Email Address: *  
     

CLAIMANT’S PARTICULARS

     
Name of Patient / Injured: *  
     
Date of Birth (DDMMYYYY): *  
     
NRIC / Passport Number:  
     
Relationship to Policyholder:  
     
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? *  
     
Are you covered under any other policy for reimbursement of medical expenses? *   Yes     No
     

(B) FOR ILLNESS

     
Nature of illness: *  
     
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
     

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, PNG or PDF format and less than 10 MB in total size.
     
File Name Size Action
     

MODE OF PAYMENT

     
My preferred way to receive payment is
     
     
We reserve the right to make payment via other modes.
     
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 reserve the right to make payment via other modes
     
Bank Details
     
Account Holder: *  
     
Bank Name: *  
     
Account No: *  
     
To receive your payment faster, please select either "PayNow" or "Credit to my bank account"
     
Name of Payee: *    
       
     

DECLARATION

     
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: *  
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