1. Policy Information

2. The Employer

 

3. The Injured Person

4. The Accident


5. The Injury




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6. The Earnings

(Please complete the following for the 12 months prior to the accident)

“EARNINGS” means - All payments in cash, for wages or salary, overtime, bonus and all other remuneration for work done (except travelling allowance or expenses, EPF or CPF contributions and special expenses incurred by reason only of the nature of employment) plus the value of all privileges or benefits in kind, for food, fuel, quarters and any other which is capable of being estimated in money (except any travelling concession).


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7. Claims Payout Instruction

8. Declaration

[Declaration] We certify that the foregoing is true and correct to the best of our belief.

[Customer’s Data Privacy Consent] We further declared that the information written in this claim form or held by Etiqa Insurance Pte.Ltd. whether contained in 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 our claim. We understand our data that may also be used for audit, business analysis and reinsurance purposes. Our signature below will signify this consent.

[Direct Credit] I/We confirm that there had not been any change to my tax residency status or any circumstances which affects my/our tax residency status and undertake to provide Etiqa with a suitably updated self-certification and documentation otherwise.

[Direct Credit] Confirm that the payment information provided by me/us in this form is true and correct and undertake to immediately inform the Company of any change in the same and will not hold the Company liable in the event that any payment transaction into my Account is delayed or cannot be effected due to incorrect or incomplete information being provided in this form, and/or for any other reason beyond the reasonable control of the Company.

[Direct Credit] Notwithstanding the above, Etiqa Insurance Pte Ltd reserves the right to release payment to me/us by cheque if we are unable to payout the claim by direct credit.

9. Documents Required for Claim Assessment

Below is a list of minimum documentation required to process your claim. Additional information may be required for further assessment.

Documents Required (Please tick against the documents you have submitted)


10. Supporting Documents Upload

Upload Supporting Documents
Please note: Total file size should not exceed 10MB.
Please only upload files that end in types: .xls, .xlsx, .doc, .docx, .jgp,.gif, .png, .jpeg, .pdf, .txt
Please attach the relevant supporting documents with your claims submission to expedite claim processing.
Drop files here to upload

11. Final Step

Please review and ensure all details are accurate before you proceed.