EQ Personal Accident 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

PARTICULARS OF POLICYHOLDER

Name of Policyholder

Contact No.

STEP 1 – POLICY & CLAIM DETAILS

PARTICULARS OF CLAIMANT

Name of Claimant

NRIC/FIN No

Date of Birth

Gender

Male

Female

Contact No

Occupation (if applicable)

Date of Employment (if applicable)

Plan No. (if applicable)

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STEP 1 – POLICY & CLAIM DETAILS

NATURE OF CLAIM

(WE / I ARE / AM MAKING A CLAIM UNDER THE FOLLOWING SECTIONS, PLEASE TICK THE RELEVANT)

Policy Benefits

Accidental Death

Permanent Disablement

Accidental Medical Expenses

Cash Benefit

Temporary Total Disablement

Temporary Partial Disablement

Others, please specify:

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STEP 1 – POLICY & CLAIM DETAILS

DETAILS OF ACCIDENT / INJURY

Date of Accident

Time of Accident

Place of accident

How did the accident happen

Describe the nature of injuries sustained

Have you sustained any injury to the same part previously?

Yes

Is this a work-related injury?

Yes

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

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

Yes

If yes, please state all the claims submitted

(i) Name of Insurer(s)

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

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STEP 2 – UPLOAD DOCUMENTS

UPLOAD DOCUMENTS

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

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

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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 DETAILS

Payment Method

PayNow

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

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STEP 4 – DECLARATION & AUTHORIZATION

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

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PERSONAL ACCIDENTCLAIM

PERSONAL ACCIDENT
CLAIM