HOSPITAL & SURGICAL CLAIM FORM

The issue of this form is not an admission of liability on the part of the company
All original medical bills & receipts must be submitted with this form to expedite claims handling
Fire & GA Claims Dept Fax: 6225 9887
A. DETAILS OF POLICY HOLDER/EMPLOYEE/PATIENT
Name Of Policyholder
Policy No
Plan
Date Of Enrolment/Cover
Name of Employee
Date Of Employment
Name Of patient
Relationship of patient to employee
Occupation of Patient
Sex
Marital Status
NRIC/Passport/BC No
Date Of Birth
If patient is not employee,
please furnish patient's employer's name
 
B. SICKNESS (THIS SECTION MUST BE ANSWERED IN FULL)
Nature Of Sickness
Date First Began
Date First Treated
Date Of Previous Treatment
Is the sickness due to pregnancy,
abortion, sterilisation or infertility?
Please specify condition
approximate date of commencement?
Date of last pregnancy, if applicable
Has The Sickness Been Treated Previously?
Name Of Physician
Address Of Physician
Did sickness arise from employment?
 
C. INJURY
Date of accident
Time of accident
Is this a job-related accident?
Describe the injury, how & when it happened?
 
D. OTHER INFORMATION
Name of hospital/clinic
Address of hospital/clinic
Date admitted
Date discharged
Date surgery performed
Are you eligible to claim for this insurance
 against any other insurance policies?
Please state:
1) insurance company
2) policy no
Claim cheques shall be made payable to
Employer S$
Employee/patient S$
Medisave S$
Medisave account no
 
MEDICAL INFORMATION AUTHORITY
I hereby authorise any hospital surgeon, medical practitioner or clinic or other person who has attended to me or examined me for any reason, to disclose to Tokio Marine Insurance Singapore Ltd any and all information with respect to any illness or injury and, to provide Tokio Marine Insurance Singapore Ltd copies of all hospital or medical records, including prior medical history. A photostat copy of this authorisation shall be considered as effective and valid as the original.

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.