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PERSONAL ACCIDENT CLAIM FORM
The company does not admit liability by the issuance of this form. The issued form
must be completed and returned within seven (7) days of receipt. No clam can be
admitted unless Medical Certificate from a duly qualified and Registered Medical
Practitioner, on the form annexed be furnished at expense of Insured. Claims Fax
No : 6225 9887
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Insured
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Insured
*
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Age
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NRIC NO
*
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Sum Insured
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Policy No
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Tel No
*
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Address
*
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Email
*
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Occupation
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Are you self employed?
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Employer Name
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Employer Address
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Do you have any other
insurance that will cover this loss?
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Please provide details:
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Have you ever made a claim under any PA policy before?
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Details of Accident
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Date
*
Time
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Place
*
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State particulars of Accident in detail
*
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Name of hospital (or clinic) taken to
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Treatment is
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(Please fill in clinic's name if not hospitalized)
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State names of witnesses to the accident
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State number of days you expect to be necessarily and entirely confined to House
or Hospital, by Doctor's orders as the sole and direct result of the injuries sustained
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To House
days
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To Hospital
days
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If still confined, state which
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To House
days
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To Hospital
days
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Do you expect in any way to attend to any part of your business or work during the
above period. If so please describe as follows
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Declaration
I hereby declare that I am the person referred to in the foregoing particulars,
that I have received the injuries before described by violent , external and visible
means. And I do further declare that I have always been uniformly sober and temperate
in my habits, and that I was no way under the influence of drugs or intoxicating
liquor when the accident occurred, and that I have not abstained from business or
work, either totally or partially, longer than absolutely necessary in consequence
of the said injuries, and that such injuries are the sole and direct cause of my
disablement or loss.
I do hereby warrant the truth of the foregoing statements in every respect, and
I agree that if I have made or in any further declaration the Company may require
of me in respect of the said accident shall make, any false or fraudulent statement,
or any suppression, concealment, or untrue avertment, the Policy shall be void as
against the Company, and my right to compensation absolutely forfeited.
I hereby claim indemnity (compensation) as provided under my Policy as follows:
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1) Temporary Partial Disablement
Weeks @
per week =
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2) Temporary Total Disablement
Weeks @
per week =
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3) Permanent Partial Disablement
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4) Permanent Total Disablement
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5) Death
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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.
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Name
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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.
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