|
|
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
|
|
|
Who is injured's employer
|
|
|
What is injured's relationship with you
|
|
|
Has injured been medically examined
|
|
|
If No, why?
|
|
|
Name of hospital (or clinic) taken to
|
|
|
Inpatient / Outpatient
|
|
|
Admitted on
|
|
|
Discharged on
|
|
|
Has injured returned to work?
|
|
|
If yes, On
|
|
|
If no, estimated period of disablement
|
from
to
Can injured do partial work?
|
|
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:
- Claim Form duly completed and signed
- Accident Report Form A or ireport with MOM
- Police Report (if applicable)
- Original medcal certificate and medical bills
- NRIC/Work Permit/Passport (Copy with photo shown)
- All third party correspondences, unanswered
- Relevant contracts to show relationship between insured and subcontractor
- 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.
|
|
|
|
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
|
|
|
|
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.
|