POLYTECHNIC GPA INCIDENT REPORT FORM

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/poly-gpa/claims.
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 “Name of 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/poly-gpa
DOCUMENTS REQUIRED (CHECK LIST)
POLICY NO. / POLYTECHNIC (Select One)
 Completed Incident Report Form
 Original Medical Bills & Receipts
 Doctor’s Memo stating Diagnosis (not medical report)
 Copy of Referral Letter to Specialist & Physiotherapist / A&E Referral Memo (if any)
 Copy of Test Written 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
Period of Insurance: 1 April 2014 to 31 March 2016
 27316098 PAG – Nanyang Polytechnic
 27316134 PAG – Ngee Ann Polytechnic
 27315706 PAG – Republic Polytechnic
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
Address (in Singapore)
Polytechnic Course of Study
Student ID No.
Date of Admission to Polytechnic
Expected Date of Graduation
 Male
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
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.
Signature of Insured Student
Date
FOR OFFICIAL USE ONLY
MYCG 01042014
MSIG Insurance (Singapore) Pte. Ltd.
Co. Reg. No. 200412212G
Scheme Managed by
NGEE ANN POLYTECHNIC
Student Group Personal Accident Insurance
HOW TO MAKE A CLAIM
1.
Prepare the Claim Documents

Complete the Student GPA Incident Report Form

Attach Original Clinic/Hospital Bills & Receipts

Attach Doctor’s Memo providing description of injury/treatment (if available)

Police Report (for traffic/death accidents)

Death Certificate (for death accident)
2.
Submit the Claims Documents
Please submit the documents to MYCG PTE LTD within 30 days from date of accident.
3.
Claims Processing Time
Claims will generally be processed within 30 days of receipt if no further documents or information is
required.
4.
Claim Reimbursement

Reimbursement will be credited to the student’s bank account

Student will be notified by email
COVERAGE PER STUDENT
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24-hours coverage worldwide
S$30,000 per student upon death or permanent disability due to an accident
S$3,000 per accident for medical expenses. Follow-up treatment will be covered up to 365 days from the
date of accident
MAIN EXCLUSIONS (THESE ARE NOT COVERED)
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Professional sports
Dangerous activities or sports, including underwater activities necessitating the use of underwater breathing
apparatus, any kind of speed contest or racing (other than on foot) boxing and wrestling, parachuting, sky
diving, bungee jumping, competitive snow or ice sports, hunting, pot-holing; the following are covered if
carried out for leisure: scuba diving under the supervision of a qualified instructor, trekking/hiking (with
licensed guides if in remote areas), rock climbing, hang-gliding, non-competitive winter sports
Suicide, intentional self-injury or wilful exposure to peril, while sane or insane
AIDS & HIV
Pregnancy or childbirth
Under the influence of drugs or alcohol
Flying or other aerial activity except as a fare paying passenger in licensed commercial air carrier or
recognized charter company
War, invasion, act of foreign enemy, hostilities, civil war, rebellion, revolution, insurrection, exercise of
military or usurped power
Ionisation, radiation or contamination by radioactivity/nuclear causes
Others - subject to the policy exclusions
TERMINATION OF COVER
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When you cease to be a full-time or part-time/ADSD/FSI student of Ngee Ann Polytechnic
Exhaustion of the cover limits during the policy year
Expiry of the insurance policy
IMPORTANT NOTE:
The information in this document is a summary only and is subject to the actual terms and conditions of the insurer’s policy
wordings. Any discrepancy between the information in this document and the policy contract is unintentional.