EQ Maid Form

STEP 1 – POLICY & CLAIM DETAILS

IMPORTANT NOTE

1.	The policyholder and/or the insured person(s) must truthfully give information and particulars to the best knowledge and belief.
2.	We are not admitting to any legal responsibility by accepting this claim form.
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 EQI as soon as possible as late claims notification may be a breach of policy condition. (please refer to policy wordings)

Policy Number

Employer’s Details

(To Be Completed By The Employer & All Fields Are Mandatory)

Name of Policyholder

Name of Authorised Representative

Contact No.

STEP 1 – POLICY & CLAIM DETAILS

EMPLOYEE'S DETAILS

Name of Employee

FIN No

Date of Birth

Gender

Male

Female

Date of Employment

Job Designation

Plan No. (if applicable)

back next

STEP 1 – POLICY & CLAIM DETAILS

DETAILS OF INJURY / ILLNESS

Due to accident

Date of Accident

Time of Accident

Is this accident work-related?

Yes

How did the accident occur

Nature of injuries sustained

For road traffic accident claim, please confirm whether the accident involving third party?

Yes

If yes, please state

(i) Vehicle No. of third party

(ii) Motor Insurer of third party

Due to illness

Date symptoms first commenced

Diagnosis / description of symptoms

Type of operation / surgical procedure

Have you claimed or do you intend to claim from any other insurer for this illness / injury?

Yes

If yes, please state

(i) Name of Insurer(s)

(ii) Details of law firm engaged (if any)

back next

STEP 2 – UPLOAD DOCUMENTS

UPLOAD DOCUMENTS

Please provide: a) Medical bills, work permit and medical memo / medical report from the attending doctor stating the nature of injury if insured person is treated as an outpatient as a result of an accident.
b) Hospital final bill, medical certificates, work permit, wages and levy statement, inpatient discharge summary / medical report if insured person is hospitalized as a result of an accident / illness.

EQ Insurance will accept electronic copies of final medical bills / tax invoices / receipts. However, we reserve all rights to request for the original documents within 12 months from the date of submission. In the event that the original final medical bills / tax invoices / receipts are not available during our review, EQ Insurance reserves the right to recover any claims that have been paid by EQ Insurance to the Policyholder / Insured Person.

Total Size : 0 MB
(Please note: Total file size should less than 10MB)

INVOICES

Delete

OTHERS

Delete

back next

STEP 3 – PAYMENT

NOTE EQ INSURANCE COMPANY LIMITED shall not be liable for any losses incurred by you as a result of providing inaccurate PayNow registered details or bank account details.
(Letter of Authorisation is required if payee for PayNow Linked Account or Bank Transfer is not the insured)

Payment Method

PayNow Linked Account

Bank Transfer

Cheque payee name

(Note: An administrative fee based on the issuing bank's prevailing charges will be imposed for every lost/re-issued cheque)

Note: please state NA if not applicable for NRIC/FIN or mobile no. or UEN

PayNow registered name

PayNow registered NRIC/FIN or mobile number

PayNow registered UEN (for corporate account)

Bank name

Bank account holder's name

Bank account number

back next

STEP 4 – DECLARATION & AUTHORIZATION

PERSONAL DATA COLLECTION STATEMENT

To evaluate, process and administer this application or transaction, it is necessarily for us to collect, use, disclose and / or process your personal data or personal information about you. Such personal data includes information collected in this form, or in any document provided, or to be provided to us by you or processed by us, or from other sources.

A. Purpose of Collection

The personal data belonging to you and your insured/s may be collected, used and disclosed for the purposes of:
1. carrying out identity checks;
2. deciding whether to insure or continue to insure you and your insured persons;
3. providing advice for product recommendation based on your profile;
4. processing any claims under your policy, including the settlement of claims and any necessary investigations relating to the claims;
5. communicating on any matters relating to the services and / or products which you are entitled to under this policy;
6. respond to your inquiries or instructions and providing ongoing services, under your policy;
7. make or obtain payments and recovering any debt owed to us;
8. detecting and preventing fraud, unlawful or improper activities;
9. conducting market research and statistical analysis;
10. coaching employees for customer service quality assurance;
11. reinsuring risks and for reinsurance administration; and
12. complying with all applicable laws, including reporting to regulatory and industry entities.

B. Disclosure of Data

The personal data belonging to you and your insured/s may be disclosed for the purposes set out in Section A above to the parties below:
1. Third party service vendors, suppliers, agents, reinsurers, or intermediaries;
2. Medical Professionals and Institutions;
3. Local or overseas service third party vendors that provide us with services such as printing, mail distribution, data storage, data entry, marketing and research, disaster recovery or emergency assistance services;
4. Debt collection agencies;
5. Dispute resolution parties;
6. Parties that assist us to investigate, administer and adjudicate claims;
7. Financial institutions;
8. Credit reference agencies;
9. Industry associations; and
10. To any regulatory, government and statutory body to comply with applicable, laws or regulation or upon their valid request.

C. Personal Data Access and Amendments

You can request access to your personal data collected by us, and to make any corrections to your personal data so as to keep it updated. We may charge you a reasonable fee for providing you with the service.

D. Withdrawal Option of the collection and use of your personal data

You may make your request to withdraw your consent, access or correct your personal data by writing to: The Data Protection Officer, EQ Insurance, 5 Maxwell Road, #17-00 Tower Block, MND Complex, Singapore 069110. Alternatively, you can email to dpo@eqinsurance.com.sg.

Neither EQ Insurance nor any of its employees shall be liable for any loss or damage suffered by you or any user as a result of any disclosure of any personal data which you have consented to us and / or any of its employees disclosing.

Altering on this “Personal data collection statement” is strictly prohibited. Any attempt to do so will be of no effect.

DECLARATION, AUTHORISATION AND DATA PRIVACY CONSENT BY INSURED

I/We 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 claim, 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 police for further investigation.
3.	In cases where I/we are not the policyholder, or in the scenario of 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 pertaining to the claims. I/we acknowledge full responsibility for ensuring the accuracy and validity of this submission. Furthermore, I/we agree to indemnify EQI against any losses or claims arising from this submission.
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 authorisation extends to disclosing details regarding illnesses, injuries, medical history, consultations, prescriptions, treatments, and any related medical records/certifications. In the case of a corporate policy, I/we confirm that I/we have gotten the same consent from the applicable insured(s) related to this claim. A photocopy of this authorisation shall be considered equally 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

Please enter Verification Code as shown below

BotDetect CAPTCHA ASP.NET Form Validation

back

MAID INSURANCECLAIM

MAID INSURANCE
CLAIM