(the company does not admit liability by the issuance of this form) Fire GA Claims Fax No: 62259887 Please fill up the General Information Section & the relevant sections listed below.
General Information
Policy No
Claimant's Full Name (if different from insured)
Tel No
Travel Period From
Travel Period To
Do you have any other insurance that will cover this loss?
If Yes, please provide details
Documents required:
  1. Original Insurance Policy
  2. Copy of all relevant pages of passport
  3. Travel Ticket & Boarding Pass
Claim under Sections 1 to 7: (please tick section claimed)
Date of Accident/onset of illness
Place of Accident/onset of
Description of Accident/Injury/Illness
Hospitalisation Period
Official cause of death if applicable
Name of doctor treating you
Address of doctor treating you
Name of usual doctor (if different from above)
Address of usual doctor
Note: For Claims Under
Sections 1 to 2: Please complete medical report form.
Sections 3 to 5: Please list your claim bills, together with documents required separately. Documents Required (as applicable):
  1. Birth Cert
  2. NRIC
  3. Death Cert
  4. Original medical/hospitalisation bills, receipts
  5. Original letter from doctor certifying that surgery cannot be delayed
  6. Original letter from doctor confirming return to S'pore was necessary.
Claim under Sections 8 to 17: (please tick section claimed)
Place of Incident
Date of Incident
Description of Incident
Please let us know if you have lodged a complaint against the Airline/Carrier?
Please fill up for claims under Section 8 or 18:
Describe items
lost damaged
Where Purchased? When Purchased? Original Purchase
Amount Claimed
(Please attach additional listing if space is insufficient) Please fill for Section 11, 12 & 16
Original Reschedule
Flight No
Place of Departure
Documents for Sect 8 to 16 (as applicable):
  1. Letter from Airline/Carrier on the cause and details of delay or loss
  2. Complaint Letter against Airline/Carrier
  3. Original receipts for items claimed
  4. Copy of report to police/relevant authority having jurisdiction at place of loss
  5. Trip cancellation/delay/overbooked documents
Documents for Sect 17 (as applicable):
  1. Police Report or other report as required in the place of jurisdiction.
  2. Rental Agreement/Receipt from a licensed rental agency
  3. Receipt for Excess/Deductible Paid
Documents for Section 18 to 19 (as applicable):
  1. Notice from SCDF/ Police/ Town Council/ MCST etc
  2. Proof of hospitalization and relationship
Note for Section 14 & 15 claims: Depending on circumstances, you will need to render your full cooperation to us or our representative (Legal).
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.
Signed Name

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