NTUC Income : Claims - Junior/Student Protection Plan Claim Form

Junior/Student Protection Plan Claim Form

1.	Name of school:
	Policy/Cert No:
	Address:
	Tel No:
	Email:
2.	Name of student:
	NRIC/BC No:	(e.g for S'pore 1234567A)
	Class:	Tel No:
	Address:
3.	Date of accident:	(dd-mm-yyyy)
	Place:
	Describe how the accident happened:
4.	Nature of claim:
	Loss of life (death)
	Total Permanent Disablement
	Medical expenses State amount incurred:
	Tutelage benefit Duration of hospital confinement:From to (dd-mm-yyyy)
5.	Cheque payable to:
	School
	Father/Mother/Guardian
	Full Name of Payee:

Declaration
I/We hereby declare that the foregoing particulars given by me/us or on my/our behalf are true and correct. Date: 03-12-2008

Name: NRIC: (e.g for S'pore 1234567A)

Rep Name: Rep Code: (e.g 123456)