TEMASEK POLYTECHNIC GPA INCIDENT REPORT FORM

TEMASEK POLYTECHNIC
GPA INCIDENT REPORT FORM
Please complete this form fully. Incomplete forms may delay claim settlement. Claims should be submitted within 30 days of treatment.
If you need more time to prepare the documents, please submit the “Claim Notification” online form at www.mycg.com.sg/tp-gpa.
CLAIMS PROCEDURE
CONTACT INFORMATION
1.
2.
3.
4.
5.
Complete this Claim Form.
Prepare/obtain the documents required in the Checklist below.
Keep a photocopy for your records.
Send the documents to “1 Coleman Street, #10-09A The Adelphi, Singapore 179803” for processing.
For follow-up claims, please send the original bills to MYCG with a note attached to state “Follow-up
Claim”, your “Full name” and “Temasek Polytechnic”.
6. Generally, we will advise you on the status within 30 days. Notification and follow-up queries will be sent
by email to you. Approved medical expense claims will be credited to the student’s bank account.
MYCG PTE LTD
Add : 1 Coleman Street, #10-09A The Adelphi,
Singapore 179803
Tel
: (65) 6635 2160
Fax
: (65) 6635 2161
Email : [email protected]
Web : www.mycg.com.sg/tp-gpa
DOCUMENTS REQUIRED (CHECK LIST)
POLICY
 Notification of Accident Form
 Completed Incident Report Form
 Original Medical Bills & Receipts
 Doctor’s Memo stating Diagnosis / A&E Treatment Record (not medical report)
 Copy of Referral Letter from Physician to Specialist/Physiotherapist (if any)
 Copy of Written Test Reports eg. x-ray, MRI (if any)
 Copy of Police Report (for traffic accidents)
 If student was hospitalised or had surgery, please submit:
 Original Final Hospital Bill (the hospital will send this to you within 2 to 3 weeks after discharge)
 Copy of Inpatient Discharge Summary (if treated at a Government/Restructured Hospital)
SECTION A
Policyholder: Temasek Polytechnic
Period of Insurance: 20 April 2015 to 23 April 2017
Policy No.: A 27879579 PAG
DETAILS OF INSURED PERSON (STUDENT)
Name of Insured Student (please write in capitals, as per bank account)
NRIC/FIN Number
Date of Birth
E-mail
Mobile/Telephone Number
Gender
 Male
Address (in Singapore)
Are you a Full-Time or Part-Time Student?
 Full-Time
 Part-Time
SECTION B
Were you or are you now on Leave of Absence
(LOA) from the Polytechnic? If so, please state
period of LOA.
 Female
Polytechnic Course of Study
Student Admission No.
Date of Admission to Polytechnic
Expected Date of Graduation
DETAILS OF STUDENT’S BANK ACCOUNT – Reimbursement for approved claims will be credited into the student’s bank account. Please DO NOT state
the bank details of another person. Please contact MYCG at [email protected] for alternative arrangements.
Bank Name (please tick)
Account Number (please write clearly)
 DBS/POSB
 UOB
 OCBC
 ___________________
SECTION C
DETAILS OF ACCIDENT AND INJURY
Description of Accident (Please state in detail how it happened)
Place of Accident
Date of Accident
Time of Accident
Description of Injury (Nature and extent of injury sustained)
Have you previously suffered
from an injury to the same part?
What is the probable period of
disablement?
Is this a work-related injury
 No
 Yes
 No
 Yes, please provide details
SECTION D
OTHER INFORMATION
Are you presently also insured for medical insurance under another Insurance Company?
Are you claiming from other Insurance Company(s)/other sources?
 No
 No
 Yes, please state Name of Insurance Company and Policy Number
SECTION E
 Yes, please provide a copy of their settlement details
MEDICAL AUTHORISATION AND DECLARATION
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.
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.
I understand and accept that my personal particulars will be collected, used and disclosed by MSIG in accordance with the Personal Data Protection Act 2012 and MSIG’s Privacy
Policy, for the provision of all services related to, and protection under, this insurance policy, including for proper servicing, underwriting and claims administration. MSIG may disclose
my personal particulars to its business partners and third party service providers for these purposes. Where there are more than one individual insured persons, I confirm they have
consented to MSIG’s collection, use and disclosure of their personal particulars. The full MSIG’s Privacy Policy can be found at www.msig.com.sg.
Signature of Insured Student
Date
MYCG 01042015
MSIG Insurance (Singapore) Pte. Ltd.
Co. Reg. No. 200412212G
Scheme Managed by