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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: *
Afghanistan
Aland Islands
Albania
Algeria
Amercican Samoa
Andorra
Angola
Anguilla
Antartica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Empire
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Island
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Danish International Register
Democractic Yemen
Democratic Rep of Congo(Zaire)
Denmark
Dominica
Dominica
East Timor
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Falkland Islands (Malvinas)
Faroe Islands
Fed States of Micronesia
Fiji
Finland
Former USSR
France
French Guiana
French Polynesia
French Southern Territories
Frmr Yugoslav Rep of Macedonia
Gabon
Georgia
German Democratic Republic
Germany
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam (Marianas)
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
Independent State of Samoa
India
Indonesia
Iran
Iraq
Ireland, Republic
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kerguelen Islands
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Madeira
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Negara Brunei Darussalam
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Ireland
Northern Marianas
Norway
Norwegian Int'l Register
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Kitts-Nevis
San Marino
Sao Tome & Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Helena
St. Lucia
St. Pierre & Miquelon
St. Vincent & Grenadines
Sth Georgia & the Sth Sandwich
Sudan
Surinam
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tahiti
Taiwan
Tajikistan
Tanzania
Thailand
The Congo
The Gambia
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S.A
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying I
United States Virgin Islands
Upper Volta
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wales
Wallis & Futuna
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe-Rhodesia
NRIC/Passport Number: *
Occupation:
Contact Number (H/O):
Mobile Number: *
Address: *
Country: *
Afghanistan
Aland Islands
Albania
Algeria
Amercican Samoa
Andorra
Angola
Anguilla
Antartica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Empire
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Island
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Danish International Register
Democractic Yemen
Democratic Rep of Congo(Zaire)
Denmark
Dominica
Dominica
East Timor
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Falkland Islands (Malvinas)
Faroe Islands
Fed States of Micronesia
Fiji
Finland
Former USSR
France
French Guiana
French Polynesia
French Southern Territories
Frmr Yugoslav Rep of Macedonia
Gabon
Georgia
German Democratic Republic
Germany
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam (Marianas)
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
Independent State of Samoa
India
Indonesia
Iran
Iraq
Ireland, Republic
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kerguelen Islands
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Madeira
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Negara Brunei Darussalam
Nepal
Netherlands
Netherlands Antilles
Neutral Zone
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Ireland
Northern Marianas
Norway
Norwegian Int'l Register
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Kitts-Nevis
San Marino
Sao Tome & Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Helena
St. Lucia
St. Pierre & Miquelon
St. Vincent & Grenadines
Sth Georgia & the Sth Sandwich
Sudan
Surinam
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Tahiti
Taiwan
Tajikistan
Tanzania
Thailand
The Congo
The Gambia
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S.A
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying I
United States Virgin Islands
Upper Volta
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wales
Wallis & Futuna
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe-Rhodesia
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
(C) BAGGAGE & PERSONAL EFFECT / LOSS OF MONEY & TRAVEL DOCUMENT
Were the Police / Authorities notified? *
Yes
No
Name of the authority reported to:
(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.
MODE OF PAYMENT
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Yes, confirm
No/Not Sure
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.