DOMESTIC SERVANT INSURANCE CLAIM FORM

The issue of this form is not an admission of liability on the part of the company
Employer's Particulars
Name
Occupation
Home Address
Passport/NRIC No.
Nationality
Telephone No.
Policy No.
Policy Type
Policy Period From To

Domestic Servant Particulars
Name
Date of Service
Nationality
Age
Gender
Work Permit No. (please attach a copy)
Passport No. (please attach a copy)

Documents Required for All Claims
Please provide the following relevant documents in support of your claims. Original of the Insurance Certificate. Original receipts for all items claimed. Hospital bills and receipts. Death Certificate for fatal case.

PERSONAL ACCIDENT & MEDICAL EXPENSES
Date Time Place
Circumstances of accident
Nature of Injury / Cause of death
Name and address of doctor attending to you
Name and address of usual doctor (if different from above)
Medical Expenses
Date of Bill Nature of Expenditure Paid To Amount

Documents Required
Medical bills; Medical Certificate; Medical receipts; Letter from Doctor certifying the permanent disability.

REPATRIATION EXPENSES
Date of repatriation
Method of repatriation
Flight No / Vessel Name
Amount Claimed

Documents Required:- Copy of airline / shipping ticket and invoice
HOSPITAL & SURGICAL EXPENSES AND WAGES COMPENSATION
Nature of illness
Date of first diagnosis
Date of first treatment
Has this condition been treated previously?
Please state name and address of doctor.
Period of hospitalisation: From To
For this illness/injury suffered, is the claimant entitled to claim against :
a) any Workmen's Compensation policy?
b) medical benefit from any other company?
give details
Documents Required :- Medical bill; Hospital bills; Medical certificate

DECLARATION
I/We hereby declare that I/WE have not withheld any material information and all statements made in this form are true.


Please download a copy of this form and send us a copy of Medical Report to be filled in by a duly qualified and registered medical pracitioner in order to process this request.
Please note that all personal information provided to TMiS is subject to the Personal Data Protection Policy Statement posted at www.tokiomarine.com.sg under privacy statement.