Submit online liability claim
Policy Information

Policy Number

Policy Holder Name

Policyholder's Email

Policyholder's Telephone Number

Do you have other insurance covering you in respect of this accident?

Yes
No
Claimant Details

Claimant is policy holder?

Yes
No
Declaration, Authorization & Customer's Data Privacy Consent

[Declaration] I/We declare that the information given in this form is true and correct to the best of my knowledge and belief. I/We understand that all information and supporting documents may be subject to review by Etiqa and Etiqa shall reserves all rights to recover any and all amounts if for any reason any claim is found to be fraudulent. Etiqa shall also reserve the right to pursue any actions at law or in equity that it deems appropriate in dealing with such fraudulent activity.

[Authorization] I/We hereby consent to and authorize the medical practitioner involved in the claimant’s care to discuss and disclose treatment details and discharge arrangements with and to Etiqa Insurance Pte Ltd. I/We agree that a copy of this consent shall have the validity of the original.

[Customer’s Data Privacy Consent] I/We further declared that the information written in this claim form or held by Etiqa Insurance Pte Ltd whether contained in my/our insurance application or otherwise obtained may be used and disclosed to your authorised staff, associated individuals and/or companies or any independent third parties (within or outside Singapore) who will provide claims administrative, advice and/or information or claims services in relation to my/our claim. I/We understand my/our data that may also be used for audit, business analysis and reinsurance purposes.

I/We agree to abide by the terms & conditions.