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 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) 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 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.
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