GOLFER'S INSURANCE CLAIM FORM

Please complete Sections A and B, and other relevant sections of this form for your claim. (Claims Fax : 6225 9887)
Section A: General Information
Name of Policyholder
Policy No
Membership No
Member's Name
Type
Occupation
Tel No
Payee's Name
(in the event the claim is payable)
Email
NRIC No
Address
Are you a member of other golf clubs?
Club Name
Membership No
Do you have any other insurance that will cover this loss?
Please provide details
Section B: Details of incident (leading to damage, loss, injury or hole in one)
Date of Incident
Time Occurred
 
Place Incident occurred
If the incident occurred on golf course, state Hole No
Did incident occur on Tee Box / Fairway / Green / Bunker / Driving Range?
Names of persons who witness Incident/Hole In One
Description of Incident
For Hole In One claims, you need to fill up only Sections A & B. Please attach letter from the golf club certifying the achievement, Hole In One Certificate, Score Card and bills and receipts in support of your claim.
Section 1: Public Liability Claims
Name of third party
Address of third party
How is the third party related to you
Extent of third party's loss or injury
State estimated amount of claim
Please let us have your views as to who is at fault
Please do not admit liability to third parties.
Section 2: Personal Accident Claims
State nature of injury sustained by you

Please submit medical report, medical certificates and medical bills for this section of claim.
Sections 3,4,5: Please fill up the following (as applicable)
Was the loss reported to the police or relevant authorities managing the place eg airport authorities, club management, shopping mall, MCST etc?  
If Yes, please attach a copy of report
Has a thorough search been conducted to retrieve the lost article(s)?
What steps have you taken to recover the lost article(s)?
Do you have any suspect in mind?
Please provide name
Have you ever made similar claims?
From which insurer?
A golfer's policy being a contract of INDEMNITY, all claims must be based upon the actual value of the articles at the time of Theft, Loss or Damage, but not exceeding the sums for which they are respectively insured, due allowance being made for depreciation and wear and tear.
Describe items lost
damaged
Where & When
Purchased?
Original Purchase
Price
Deduction for
Wear & Tear
Amount Claimed
Please attach all original bills and receipts. Please attach additional listing if space is insufficient 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.

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.