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
Insured
Insured

Age
NRIC NO
Sum Insured
Policy No
Tel No
Address
Email
Occupation
 
Are you self employed?  

Do you have any other insurance that will cover this loss?
Please provide details:
Have you ever made a claim under any PA policy before?

Insurer
Amount
Date
Details of Accident
Date

Time
Place
State particulars of Accident in detail
Name of hospital (or clinic) taken to
Treatment is
(Please fill in clinic's name if not hospitalized)
Admitted on
Discharged On
State names of witnesses to the accident
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
To House  days To Hospital  days
If still confined, state which
To House  days To Hospital  days
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
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:
1) Temporary Partial Disablement
 Weeks @  per week =
2) Temporary Total Disablement
 Weeks @  per week =
3) Permanent Partial Disablement
4) Permanent Total Disablement
5) Death
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.
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.