EQI Online Windscreen Claim Request

STEP 1 OF 6

IMPORTANT NOTE

1.	The policyholder and/or the insured person(s) must truthfully give information and particulars to the best knowledge and belief.
2.	By completing this form, it is not an admission of liability or acceptance of claim by EQ.
3.	If the claim is found to be fraudulent, or if any fraudulent means or devices are used to obtain any policy benefits, the policy will be rendered void.
4.	Notify or submit your claims to EQ as soon as possible as late claims notification may be a breach of policy condition. (Please refer to policy wordings)
5.	Windscreen claims must be submitted to EQ Claims Dept within 14 days from date of loss.

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STEP 2 OF 6

WORKSHOP INFORMATION

Name of Workshop

Contact No.

Email Address

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STEP 3 OF 6

POLICY DETAILS

Name of Policyholder

Contact No.

Email Address

Policy Number

Vehicle Number

ACCIDENT DETAILS

Date and Time

Location

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STEP 4 OF 6

DAMAGE DETAILS

Cause of Damage

Describe Cause of Damage

Was a Third Party / Pedestrian involved?

Yes

No

Name of Third Party / Pedestrian

Contact No. of Third Party / Pedestrian

Section of Glass Damaged

(click to add if there is other glass damage)

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STEP 5 OF 6

RECIPIENT EMAILS

Please input email address of recipient(s) other than the workshop and the policyholder to receive a copy of completed claims form (in PDF). Leave empty if not required.

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STEP 6 OF 6

DECLARATION, AUTHORISATION AND DATA PRIVACY CONSENT

I/We have read, understood, and agreed to the content, and hereby declare and warrant the following:

1.	All statements and answers provided in this form are complete, accurate, and true to the best of my/our knowledge and belief.
2.	I/We understand that any false or fraudulent statements, as well as any attempt to conceal material facts related to this submission, may result in the forfeiture of all rights to claim under the policy. In such instances, EQ Insurance Company Limited (“EQI”) reserves the right to report the matter to the relevant authorities for further investigation.
3.	In instances where I/we am/are not the policyholder, or where the policy is a corporate policy, I/we confirm that I/we have been duly authorised by the insured member(s) (hereafter referred to as the “Insured”) to provide relevant information for this submission. I/We accept full responsibility for the accuracy and validity of the information submitted and agree to indemnify EQI against any losses or claims arising therefrom.
4.	I/We authorise and consent to the release of any and all relevant information, as requested by EQI or its authorised representatives, from hospitals, doctors, individuals, or organizations that have provided medical care, conducted examinations, or maintain medical records for me/insured. This includes, but is not limited to, information regarding illnesses, injuries, medical history, consultations, prescriptions, treatments, and related records or certifications. In the case of a corporate policy, I/we confirm that I/we have obtained the necessary consent from the relevant Insured(s) for the release of such information. A photocopy of this authorisation shall be considered as valid as the original.
5.	I/We hereby grant permission and consent to EQI for the collection, usage, disclosure, and processing of my/our personal data. Additionally, I/we authorise the sharing of such pertinent information with EQI’s authorised representatives, intermediaries, third-party service providers, reinsurers, legal entities involved in the claims process, government/regulatory bodies, industry associations, courts, and other dispute resolution forums, for the purposes and uses described in EQI's Personal Data Protection Statement available at www.eqinsurance.com.sg which is in alignment with legal, regulatory obligations, and risk management procedures.

Date

Verification Code

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WINDSCREEN CLAIM REQUEST