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Medical/Personal Accident Online Claim Form
 
(General Insurance Only)
When completing this form, please note:
(1) Do not leave any answer blank. Where a question is not applicable, please indicate 'NA' or 'Nil'.
(2) If you are claiming for medical expenses, original hospital/medical bill(s) and receipt(s) must be submitted.
(3) Not to be use for managed healthcare claims.
Policy No:
Name of Policyholder:
NRIC No: (e.g for S'pore 1234567A)
Occupation:
Address:
Postal Code:
Email:
Contact No: (H/O)       (Pager/Hp)
 
Name of Patient/Injured:
Date of Birth: (dd-mm-yyyy)
NRIC No: (e.g for S'pore 1234567A)
Relation to Policyholder:
Occupation:
Employer:
 
Name of Hospital/Clinic:
Date of Admission: (dd-mm-yyyy)
Date of Discharge: (dd-mm-yyyy)
Nature of illness or injury:
Since when did the patient have this problem? (dd-mm-yyyy)
Name/Nature of Surgical Procedure:
Date of Surgery: (dd-mm-yyyy)
 
(a) When was the first time the patient consulted a doctor for the problem?
Date (dd-mm-yyyy)
Name and Address of Doctor:
Other date(s) of consultation:
(b) Did the patient consult any other doctor(s) for the problem?
Yes No
if yes, please give
(i) Name and Add of doctor(s)

(ii) Date(s) of consultation:
Is the patient's condition due to pregnancy, infertility or childbirth (or complications arising therefrom):
Yes No    
If yes, please give details:
 
Has the patient required medical or surgical treatment during the past 5 years?
Yes No    
If yes, please give details:
  For Injury Cases, Please Answer these Questions
(a) When did the accident happen?
Date:
 (dd-mm-yyyy)
Time:
Place:
(b) How did the accident happen?
(c) Names and addresses of any witnesses to the accident:
(d) Did the injured consume any alcohol or drugs prior to the accident?
If yes, please give name of items consumed and the quantity:
(a) Is the patient covered under any other policy for reimbursement of medical expenses?
Yes No
If yes, please give name of insurance company and policy number:
(b) Does the patient's employer have any other policy (eg. Workmen's Compensation) covering him/her for medical expenses?
Yes No
If yes, please give name of insurance company and policy number:
(c) Is a claim being made for medical expenses from the insurance company named in (a) and (b)?
Yes No
  Declaration

I/We hereby warrant that the above statements are true and complete and I/We have not withheld any material fact from the society.

Date : 22-11-2008

Name:       
NRIC No: (eg. for S'pore 1234567A)

Rep Name:       Rep Code: (eg. 123456)
 
 

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