FIDELITY GUARANTEE CLAIM FORM

The company does not admit liability by the issuance of this form.
Fire GA Claims Fax No: 6225 9887
Employer
Insured
Policy No
Nature of Business
Contact Person
Email
Tel No
NRIC No
Address

Employee
Name
NRIC
Present or last known address
Occupation
Please list details of any salary/ commission, other allowance which but for this default would have been due to employee
Does employee own any asset?
Please give details
Have you any Indemnity or Security from the defaulter other than the above policy?
Please give details

Default
Date of discovery
Since what date has default occured
In what manner was it concealed
What led to its discovery
Has there been any previous irregularity if the defaulter's accounts
Please give details
Amount of default ascertained so far?
Is this the final amount

NB: The final claim should be presented within 3 months with full details showing how it is calculated.

Important Notice: The insured person must, in the event of a claim, advise the company as to any other insurance that they may have covering the same risk.

Declaration: I hereby declare and warrant that all the answers given above to be true. I accept that insurers would be at liberty to deny liability in part or in full if the above written answers are false or inaccurate in any aspect.
Designation
Name

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.