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Work Injury Compensation Online Claim Form
 

IMPORTANT:
This form must be completed and returned to the Society AS SOON AS POSSIBLE. Please note that no liability is admitted by the Society by the issue of this form.

  Particulars Of Insured
Name:
Policy No.:
Address:
Postal Code:

Business:
Tel No:
Total no. of Employees:         No. of Workmen:
  Particulars Of Injured Worker
Name:
Address:
Postal Code:
Occupation:
Sex: Male Female
Date of birth: (dd-mm-yyyy)
NRIC/FIN No: (e.g for S'pore 1234567A)
Marital Status: Single      Married       Widowed      Divorced
Date worker joined your service: (dd-mm-yyyy)
Citizenship:
Is the worker under your direct employ? Yes No
If not, please give name and address of his direct employer.
Name of direct employer:
Address of direct employer:
  Particulars Of Accident
Date : (dd-mm-yyyy)    Time:
Place:
Date you were informed of the accident: (dd-mm-yyyy)
Please give detailed account of the accident:


Please give names of persons who witnessed the accident:
Please give details of injury (state part of body injured, nature of injury, etc)
State place where injured worker received treatment
If hospitalised, state whether still in hospital or when discharged:
Hospitalised Discharge (dd-mm-yyyy)
If the worker has returned to work, give the date he did so. (dd-mm-yyyy)
State the probable period of his disablement.
Has the Commissioner for Labour been notified of the accident?
Yes No

Please give the worker's gross monthly earnings during the 12 months preceding the date of the accident:
Month Gross Monthly Earnings
(Excluding Bonus)		 Annual Wage Supplement/Bonus
Paid During Last 12 Months
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
S$ S$
TOTAL S$ S$
 
  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: (eg. for S'pore 1234567A)
Email:

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

 
 

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