PERSONAL LINES
PROPERTY 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: *  
     

PARTICULARS OF ACCIDENT / CLAIM

     
Nature of loss or damage: (e.g. Fire / Water Damage / Accidental Damage / Loss / Burglary / Money)  
     
Date of Accident (DDMMYYYY): *         Time of Accident (HHMM): *
     
Where did it occur?  
     
By whom was the item last seen and where?  
     
How was the loss/damage caused?  
     
When was the police report made?  
     
Are you the sole owner of the damaged / lost property? *   Yes     No
     
Are there any tenancy / mortgage contracts involved?   Yes     No
     
Are there any other insurance policies covering the property concerned? *   Yes     No
     
If yes, please specify:  
     

DETAILS OF CLAIMS

     
Details of Property Lost or Damaged
 

1) Describe the property lost/damaged and the extent of the damage   Date Acquired
(DDMMYYYY)
  Deduction for age, use and/or wear and tear or value of salvage
     
           
  Place Purchased From   Price Paid (S$) Net Amount of Claim (S$)
     
     

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: *  
     
Date (DDMMYYYY): *  
     
Verification Code: *  
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