CLAIM FORM – MAID INSURANCE
Please do not submit a new e-claim for an existing / a follow-up claim. For any follow-up claim, if you have any further claim documents to submit, please indicate our claim reference number and send it to anhclaims@eqinsurance.com.sg
Policy Number:
Name of Intermediary:
PARTICULARS OF POLICYHOLDER
Name of Policyholder:
Address:
Postal Code:
Name of Authorised Representative:
Email of Authorised Representative:
Contact No. of Authorised Representative:
PARTICULARS OF CLAIMANT
Full Name:
FIN No:
Date of Birth
(DD/MM/YYYY)
Gender:
Occupation (if applicable):
Date of Employment
(DD/MM/YYYY)
Plan No. (if applicable):
DETAILS OF INJURY / ILLNESS
Date of Accident
(DD/MM/YYYY):
Time of Accident:
Is this accident work-related?
How did the accident occur:
Nature of injuries sustained:
For road traffic accident claim, please confirm whether the accident involving third party?
If yes, please state:
(i) Vehicle No. of third party:
(ii) Motor Insurer of third party:
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?
If yes, please state all the claims submitted:
(i) Name of Insurer(s):
(ii) Details of law firm engaged (if any):
THIS SECTION MUST BE COMPLETED
PAYMENT DETAILS
Payment Method:
Cheque payee name:
(Note: An administrative fee based on the issuing bank's prevailing charges will be imposed for every lost/re-issued cheque)
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:
Email Address:
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)
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.
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.

Total Size : 0 MB
(Please note: Total file size should less than 20MB)
INVOICES
OTHERS
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, 77 Robinson Road #12-01 Robinson 77 Singapore 068896. 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
I hereby declare that the information stated on this form is true and correct to the best of my knowledge and belief.

I understand that any false or fraudulent statements or any attempt to withold material facts whatsoever in respect of this claim, I shall forfeit all rights to claim under the policy.

By assessing or using this System, in instances where I am not the policyholder and/or insured, I warrant and represent that I have been properly authorized by the policyholder and the applicable insureds (collectively, hereafter the ‘Insured’) to submit information pertaining to such Insured’s claims. I note that I am fully responsible for ensuring the validity of this submission and agree to indemnity EQ INSURANCE COMPANY LIMITED against any loss or claims thereof.

I hereby authorise any hospital, doctor, person(s) or organisation(s) who has / have attended to me/insured for any reason, to disclose to EQ INSURANCE COMPANY LIMITED or its authorised representatives, any and all information with respect to any illness or injury and to provide copies of all hospital or medical records / certifications, consultation, prescription or treatment, including earlier medical history.
A photocopy of this authorisation shall be considered as effective and valid as the original.
Date (DD/MM/YYYY):
Verification Code:
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