PERSONAL LINES - TRAVEL ONLINE CLAIM FORM

Date Incurred
(DDMMYYYY)

Details of Expenses Incurred (including patient's name)

Amount Claimed (S$)

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

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: *		Please enter Verification Code as shown below



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