Travel Insurance Claim Form

MSIG Insurance (Singapore) Pte. Ltd.
4 Shenton Way #21-01 SGX Centre 2 Singapore 068807
Claim Hotline: (65) 6827 7660 (24 hours) Fax: (65) 6225 6371
Co. Reg. No. 200412212G
Travel Insurance Claim Form
Policy Number
Please note that this form is issued without admission of liability. Please state all relevant information requested as complete and as accurate as possible.
Personal Particulars of Insured / Insured Person / Claimant
Name of Insured (as in NRIC/Passport - if applicable)
NRIC / Passport Number (if applicable)
Contact Number
(H)
(O)
Name of Insured Person / Claimant (if it differs from Insured)
Email
(HP)
NRIC / Passport Number
Home Address
Gender
q Male
Date of Birth (dd/mm/yyyy)
Contact Number
(H)
Travel Period:
Occupation
q Female
Relationship to Insured
Email
(O)
(HP)
From (dd/mm/yyyy)
To (dd/mm/yyyy)
Details of Claim
Date of Occurrence (dd/mm/yyyy)
Time
Country of Occurrence
q am
q pm
Description of Incident, Loss or Illness
Types of Claim (please q tick where appropriate)
A.
q Personal Accident
q Medical Expenses
q Emergency Medical Evacuation & Repatriation
Supporting documents required include:
= Travelling itinerary, airline ticket, boarding pass or copy of passport with stamp which shows the date of departure and return to Singapore
= Original medical receipt/bills
= Medical Report
= All other documents which can facilitate the consideration of claim
Nature and Extent of Injury / Illness / Disease:
Have you ever suffered this or a similar condition or a recurrence of a previous illness or injury?
q Yes q No
If Yes, date of symptoms first started/treated:
Name and Address of your usual attending Physician:
Will there be any more bills to be submitted?
Date Incurred
q Yes
q No
Details of Expenses Incurred
Amount to be Claimed
(state currency if not in S$)
Medical Authorization (This portion must be completed by the Insured Person / Claimant)
I hereby authorize any hospital physician or other person who has attended or examined me to furnish to the Insurer or its representative any and all information
on my illness, injury, medical history, consultations, prescriptions or treatment, with copies of all hospital or medical records. A photocopy of this authorization
shall be considered as effective and valid as the original.
Signature of Insured Person / Claimant
Name of Insured Person / Claimant
CLM-TRV-0711
B.
q Personal Baggage
q Baggage Delay
q Loss of Personal Money q Loss of Documents and Passport
Supporting documents required include:
= Travelling itinerary, airline ticket, boarding pass or copy of passport with stamp which shows the date of departure and return to Singapore
= Police Report
= Property Loss / Damage Irregularity Report / Baggage Return Acknowledgement Slip
= Photographs of damaged items
= Purchase invoices / warranty cards (if applicable) for items claimed
= All other documents which can facilitate the consideration of claim
Has this loss/damage been reported to the authorities/police?
If Yes, authorities/police reported to:
If No, please state reasons:
q Yes
Any compensation received from carrier/other parties responsible for the loss?
Full Description of Item(s) Claimed
Including Brand and Model
q No
q Yes q No Amount Received:
Name and Address from whom
Goods were purchased
Date of
Purchase
Original
Purchase Price
Amount
Claimed
For Baggage Delay
The destination where this occurred and the date and time you arrived
The date and time you eventually received your baggage
C.
q Travel Delay q Overbooking / Missed Connection of Flight q Cancellation q Curtailment
Supporting documents required include:
= Travelling itinerary, airline ticket, boarding pass or copy of passport with stamp which shows the date of departure and return to Singapore
= Carrier's/airline's written confirmation on the reason and period of disruption/interruption to the trip
= Hotel accommodation confirmation advice / Travel deposit receipt
= All other documents which can facilitate the consideration of claim
Scheduled Departure Date
Time
Final Departure Date
Time
q am q pm
q am q pm
Cause of Delay / Missed Connection
Flight Number
Flight Number
Duration of Delay
hours / day
Reason for Cancellation / Curtailment
Total Amount Paid for the Trip
D.
Total Refund Received
Cancellation/Postponement Charges
q Rental Vehicle Excess Cover
q Additional Costs of Rental Car Return
Supporting documents required include:
= Original Rental Vehicle Agreement/Contract
= Evidence of motor accident / Police Report
= Original Excess Payment Receipt
Period of Hire
Date and Time the vehicle is returned
Reason of late return (if applicable)
Amount Claimed
E.
Amount Claimed
q Others
In respect of any other claim which does not fall within the sections stated above, please provide details and supporting documents of the claim you are
submitting. If the space below is insufficient, please attach another page.
OTHER INSURANCE / INFORMATION
Is there other insurance covering this incident?
If Yes, please state Name of Insurance Company & Policy Number:
q Yes
q No
Have you made any previous claims in respect of Travel Insurance?
If Yes, please give details
q Yes
q No
Declaration
I/We declare that the information given is true and correct to the best of my/our knowledge and belief. I/We understand that any false or fraudulent statements
or any attempt to suppress or conceal any material facts shall render the policy void and I/we shall forfeit my/our rights to claim under the policy.
Please make the cheque payable to
Signature of Insured / Insured Person / Claimant
Company's Stamp (if applicable)
Name
Date