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tRAVEL iNSURANCE Online Claim Form
 

(No liability is admitted by the issue of this form)
  Personal Particulars
Name of insured:       Age:
Sex: Male Female
Address:       Postal Code:
Contact No.:       Cert. No.:
Occupation:
Email:
If you wish payment to be credited to your bank account, please let us have:
Name of bank:
Branch:
Account No.:
 
  Common Details
  (This section must be completed)
Where did the loss/accident/incident/illness occur?
Date: (dd-mm-yyyy)        Time:
 
Description of the loss/accident/incident/illness:
 

Are there any other insurance policies covering you in respect of this event? If "Yes", please give names of insurers, policy numbers and amounts recovered or recoverable:
Yes No
 
1. Name of Insurer: Policy No.:
Amount Recoverable:
2. Name of Insurer: Policy No.:
Amount Recoverable:
 
  Specific Details
(Please tick ONLY those benefits you are claiming and answer the questions accordingly)
Personal Accident Benefit
What injuries have you sustained?
Do the injuries sustained result in permanent disablement? Yes No
Medical Expenses
Hospitalisation:       Outpatient:
Cancellation/Curtailment Cover
What is the cause of the cancellation?
State the amount claimed: (show working if neccessary)
Amount claimed:
Working:
Overbooked Flight/Missed Connection
What is the number of the overbooked flight/missed connection?
If your claim is for missed connection, what is the number of the earlier flight?
What is the duration of its delay?
Travel Delay
What is the name of the conveyance delayed?
What is the number of the conveyance delayed?
Date of departure as scheduled: (dd-mm-yyyy)
Time of departure as scheduled:
What is the cause of the delay?
Date of actual departure: (dd-mm-yyyy)
Time of actual departure:
Personal Liability
What is the name of the other party?
What is the address of the other party?
Has a claim been made against you?
If "Yes", give details and forward all communication received.
Personal Baggage Benefit
Did you report the loss/damage to any authority? Please specify. Yes No
Name of the authority reported to:
Items lost/damaged Cost Date of Purchase
1. S$ (dd-mm-yyyy)
2. S$ (dd-mm-yyyy)
3. S$ (dd-mm-yyyy)
Baggage Delay

Duration of the delay:
Date: >From to (dd-mm-yyyy)
Time: >From to


Note:
Airtickets, boarding passes, relevant invoices and other documents to support your claim should accompany this form.

I/We the undersigned hereby declare that all the foregoing particulars given by me/us are true and correct.

I/We hereby consent to NTUC Income obtaining medical information from any hospital, physician and any other person(s) I/my have consulted and I authorise the giving of such information. I agree that a photocopy of this form shall be as valid as the original.

Date : 03-12-2008

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

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

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