WORK INJURY COMPENSATION ACCIDENT REPORT FORM

(the company does not admit liability by the issuance of this form) Particulars of every accident to be furnished and signed by the employer. FGA Claims Fax No (65) 6225 9887
Employer Information
Policyholder
Policy No
NRIC No
Address
Tel No
Email
Contact Person
Business
Total Number of employees
Are you GST Registered?
Agency/Broker
Do you have any other insurance that will cover this loss?
If Yes, please provide details
The injured person
Name
NRIC/Passport/Work Permit No
Nationality
Age
Sex
Local Address
No of working days per week
Occupation of injured
What was injured doing when accident happened
Is injured your employee?
Start of service
End of service
Has injured been medically examined
Name of hospital (or clinic) taken to
Inpatient / Outpatient
Admitted on
Discharged on
Has injured returned to work?
If yes, On
Are you satisfied that injured met with a bona fide accident of employment?
Nature/Region of Injury
On the
For fatal accident
State official cause of death
Will an enquiry be held?
Additional Information
For fatal cases and cases where injured is unable to take care of his/her daily affairs, please provide a separate listing stating dependent's name, addresses, relationship, age, and occupation.
The Accident
Date
Time
Place
When were you notified of accident?
Who notified you of accident?
Date injured actually ceased work
State the general nature of work going on when the accident happened?
Explain the accident in detail
If machinery used, state what machinery
Was injured under the influence of drugs or alcohol at the time of accident?
Was injured guilty of any misconduct or disobedience to order or rules?
If yes, give details
Whose neglect caused accident?
Any witnesses to the accident?
Witness Name
Witness Employer
Witness Tel
Was accident reported to Ministry of Manpower, Commissioner for Labour?
If Yes, please attach a copy of ireport or Form A
If No, reasons
General Documents Required:
  1. Claim Form duly completed and signed
  2. Accident Report Form A or ireport with MOM
  3. Police Report (if applicable)
  4. Original medcal certificate and medical bills
  5. NRIC/Work Permit/Passport (Copy with photo shown)
  6. All third party correspondences, unanswered
  7. Relevant contracts to show relationship between insured and subcontractor
  8. Salary Vouchers (12 months before date of accident) Please submit above as applicable. We will write to you separately for further information as necessary.
Statement of Wages
Statement wages which have fallen due for payment to injured in the employ of insured for 12 months prior to the date of accident, or wages earned during such shorter period as injured may have been in insured's service, stating the date in which he was engaged.
Month/Year (MM/YY) Basic Wages Overtime, Bonus,
Value of free quarters,
Other allowances
Total
Total including all allowance
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/we hereby declare and warrant that all the answers given above to be true. I/we 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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