TM XPLORA - TRAVEL PERSONAL ACCIDENT CLAIM FORM

TM Travel Claim Form (the company does not admit liability by the issuance of this form) Please fill in the sections on General Information & the relevant sections that you want to claim. Please send the duly signed form to the above listed address marked for the attention of Fire and GA Claims Department. Email: tmisclaims@tokiomarine.com.sg
GENERAL INFORMATION
Insured
Policy No
Claimant's Full Name (if different from insured)
Address
Tel No
Email
Travel Period from
Travel Period to
Destination
Do you have any other insurance that will cover this loss
If Yes, please provide details
Actual circumstances of incident leading to this claim.
PERSONAL ACCIDENT PROTECTION (indicate claim amount)
Accidental Death & Permanent Disablement  
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Double Indemnity for travelling in Public Transportation  
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Child Education Grant
Lump sum payable for Your dependant
Child/Children as a result of Your Accidental death
Documents Required (as applicable):
a) Death Cert
b) All documents supporting the reasons as stated for the above
c) Depending on circumstances, you will need to render your full cooperation to us or our appointed representative for further inquiry.
MEDICAL COVERAGE (indicate claim amount)
Medical Expenses incurred Overseas  
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Medical Expenses incurred in Singapore
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Medical Expenses - Pregnancy Related  
Reimburses medical expenses incurred overseas
due to pregnancy-related sickness after the first trimester of pregnancy.
Chinese Physician / Chiropractor
Covers Chinese Physician treatment overseas and/or in Singapore
Overseas Hospital Confinement Allowance  
Pays S$200 for every complete day You are hospitalized overseas
Hospital Visit  
Pays for one Relative or friend to visit You if
You are hospitalized overseas for more than 5 consecutive days
Compassionate Visit  
Pays for one Relative or friend to assist in the
final arrangement in the event of Your death whilst overseas
Child Care  
Pays for one Relative or friend to accompany Your Children covered under the Family Plan back to Singapore following Your hospitalization whilst overseas
Emergency Medical Assistance & Evacuation  
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Repatriation Expenses  
Pays for transporting the mortal remains back to
Singapore or Your Country of Origin
Special Grant  
Lump sum payable as a result of Your death due to an Injury or Sickness whilst overseas
Emergency Telephone Charges  
Reimburses You for telephone charges incurred in contacting Allianz Global Assistance for 24 hours medical assistance
Documents Required (as applicable):
a) Birth Cert
b) NRIC
c) Original medical/hospitalisation bills, receipts
d) Original letter from doctor certifying that surgery cannot be delayed
e) Original letter from doctor confirming return to S'pore was necessary.
TRAVEL INCONVENIENCE (indicate claim amount)
Trip Cancellation
Reimburses You for unredeemable travel & accommodation expenses paid in advance and
occurring within 60 days before the Trip commences
Trip Postponement
Reimburses additional administrative charges incurred for postponing the Trip occurring
within 30 days before the Trip commences
Trip Cancellation due to Insolvency of Travel Agency
Reimburses You for travel deposits paid in advance in the event of Insolvency of travel agency
Trip Curtailment
Reimburses You for additional travel & accommodation expenses incurred or forfeited, if it is necessary for You to curtail the Trip
Disruption/Withdrawal of Hotel Services
Pays $100 for each full 24 hours in the event of disruption or withdrawal of services at a hotel overseas as a result of strike or riot
Personal Baggage and Effects
Covers loss or damage to Your Personal Baggage and Effects
Travel Documents
Pays for the cost of replacing Your travel document including the additional travel and hotel accommodation expenses incurred 
Loss of Personal Money  
Covers loss of money due to robbery, burglary or theft
Travel Delay  
Pays S$100 for each full 6 hours of delay
Baggage Delay  
Pays S$200 for each full 6 hours of delay
Emergency Purchases  
Pays for emergency purchase of essential personal items if your baggage is stolen or permanently lost
Overbooked Flight/Voyage/Train  
Reimburses You for expenses incurred for additional accommodation, meals and refreshments due to
overbooked flight, voyage or train for at least 6 consecutive hours
Missed Flight Connection  
Reimburses You for expenses incurred for additional accommodation, meals and refreshments due to
missed connecting flight for at least 6 consecutive hours
Flight Diversion  
Pays S$100 for each full 6 hours of delay
Travel Interruption  
Reimburses the unused portion of the Trip if You
are hospitalized overseas for more than 5 consecutive days
Personal Liability  
Covers You against legal liability to third party
Aircraft Hijacking  
Pays S$500 (Premier) or S$300 (Classic) for each full 6 hours
Kidnap and Hostage  
Pays S$200 (Premier) or S$100 (Classic) for each full 24 hours
Documents Required (as applicable)  
a) Letter from Airline/Carrier on the cause and details of delay or loss
b) Complaint Letter against Airline/Carrier
c) Original receipts for items claimed
d) Copy of report to police/relevant authority having jurisdiction at place of loss.
e) All other documents and invoices supporting the reasons as stated for the above.
f) Depending on circumstances, you will need to render your full cooperation to us or our appointed representative for further inquiry.
BONUS COVER (indicate claim amount)  
Golf Equipment  
Covers loss or damage to Golf Equipment
Rental Vehicle Excess  
Reimburses You for any excess or deductible payable
by You due to Accidental loss or damage to Your rental vehicle
Home Care  
Covers loss or damage to Your household contents
due to fire to Your residence which was left vacant during Your Trip
Quarantine Following Infectious Diseases  
 Pays $50 for each full 24 hours of quarantine
Full Terrorism Cover  
(including use of Nuclear, Chemical and Biological weapon) aggregate limit for Sections 1, 3 to 37 and 39.
Cover for Insured Person (below 70 years)
Cover for Insured Person (70 - 79 years old)
Cover for each Child included in Family Plan
Group Policy – Maximum Limit per Policy
Loss of Credit Card  
Pays for fraudulent usage on Your credit card
Documents Required (as applicable):  
a) Police Report or other report as required in the place of jurisdiction.
b) Rental Agreement/Receipt from a licensed rental agency
c) Receipt for Excess/Deductible Paid
d) All documents supporting the reasons as stated for the above including original receipts & tour operator's booking invoice.
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. We reserve the rights to ask for further documents and clarifications. 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.