PERSONAL LINES
TRAVEL 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 LOSS / INCIDENT / ILLNESS

     
Date of Accident (DDMMYYYY): *         Time of Accident (HHMM): *
     
Where did it occur? *  
     
Description of
loss/incident/illness: *
 
     
Please select the section relevant to your particular claim:
     

(A) PERSONAL ACCIDENT BENEFIT

     
Nature and extent of injuries sustained: *  
     

(B) MEDICAL EXPENSES / HOSPITAL BENEFIT

     
Were you hospitalised? *   Yes     No
     
Expenses Incurred    

    Date Incurred
(DDMMYYYY)
  Details of Expenses Incurred (including patient's name)   Amount Claimed (S$)
1)      
 
     

(C) BAGGAGE & PERSONAL EFFECT / LOSS OF MONEY & TRAVEL DOCUMENT

     
Were the Police / Authorities notified? *   Yes     No
     
Name of the authority reported to:  
     

    Full Description of Article(s) Claimed   Date of Purchase
(DDMMYYYY)
  Original Purchase
Price (S$)
1)      
 
    Name and Address from whom Goods were purchased   Amount Claimed (S$)
     
 
     

(D) BAGGAGE DELAY

     
Duration of the delay
     
From Date (DDMMYYYY): *   Time (HHMM): *
     
To Date (DDMMYYYY): *   Time (HHMM): *
     

(E) MISSED CONNECTION / FLIGHT DELAY OR OVERLOADING

     
Departure as Scheduled
     
Date (DDMMYYYY): *   Time (HHMM): *
     
Place of Departure:  
     
Flight Number:  
     
Cause of the delay: *  
     
Actual Departure
     
Date (DDMMYYYY): *   Time (HHMM): *
     
Place of Departure:  
     
Flight Number:  
     

(F) CANCELLATION / CURTAILMENT

     
Planned Departure Date (DDMMYYYY): *  
     
Reason for Cancellation: *  
     
Date of Cancellation
(DDMMYYYY): *
 
     
Amount Paid for the Trip (S$): *    Please fill in the amount equivalent to Singapore dollar.
     
Refund Received (S$):    Please fill in the amount equivalent to Singapore dollar.
     
Amount Claimed (S$): *    Please fill in the amount equivalent to Singapore dollar.
     

(G) RENTAL VEHICLE EXCESS COVER / ADDITIONAL COSTS OF RENTAL CAR RETURN

     
Date the Vehicle is returned (DDMMYYYY): *   Time (HHMM):
     
Period of Hire From (DDMMYYYY): *   To (DDMMYYYY): *
     
Reason of late return (if applicable):  
     
Amount Claimed (S$): *    Please fill in the amount equivalent to Singapore dollar.
     

(H) OTHER INSURANCE / INFORMATION

     
Do you have other insurance covering this incident?   Yes     No
If click Yes, Name of Insurance Company & Policy  
     
Are you making the same claim from other source?   Yes     No
If click Yes, Name of company and amount claimed  
     
Have you made any previous claim in respect of Travel Insurance?   Yes     No
If click Yes, Provide details of the claim  
     

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
     
For PayNow, the NRIC/FIN provided must be that of the policyholder. Otherwise, we will be unable to make the payment via PayNow and reserve the right to switch and pay using another payment mode.

If you have registered for your PayNow with your mobile number, please do not continue with the PayNow option. 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: *  
     
Date (DDMMYYYY): *  
     
Verification Code: *  
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