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File A Claim

File A Claim
File A Claim

Fidelity Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

B. Claimant Details

Full Name


Telephone No.

Is your Company GST Registered?

C. Loss Details

Name of the Employee

Address of the Employee

Mobile No. of the Employee

Date of Employment


Renumeration (SGD)

Date of Termination

Has the employee been continuously in your service since the date of employment?

Please provide details

When was it discovered?

Who discovered it?

Date the Employee first committed the act of fraud or dishonesty. If there were more than one occasion, state the respective dates of such acts of fraud or dishonesty.

Date of Incident

Incident #1
+ Add another entry

By what method and in what circumstances were the acts of the fraud or dishonesty committed?

What were the losses

What were the value of the losses? (SGD)

Does the employee agree with the amount of the deficiency?

Are there any checks and supervision in place? If yes please provide name of supervisor

Was there any previous similar incident committed by the Employee?

Please provide details:

Is there any other insurance covering the same loss?

Please provide details:

Any money or property in your custody due or belongings to the employee? Please note that any such money or property should be retained by you pending our instructions

Please specify amount (SGD):

Do you know the present whereabouts of the employee?

Please give precise details:

Are you in communication with the employee or with any member of his/her family?

Please provide details:

Have you removed from the employee’s custody all goods or other property belonging to you?

Please provide details:

Have this employee’s customers (if any) been advised that he/she no longer has the authority to represent you?

Has any report been made to the police?

D. Bank Account Details

Please provide your bank details for us to accelerate your claims payment process by direct transfer to your bank account.

Name (as per bank account)

Bank Name

Bank Code

Account No.

Branch Code

E. Declaration, Authorization & Customer's Data Privacy Consent

[Declaration] I/We confirm that I am/We are the claimant and/or the Policyholder and I/We declare that all the particulars given above are to the best of my/our knowledge true and correct.

[Authorization] I / We hereby consent to and authorize the medical practitioner involved in the claimant’s care to discuss and disclose treatment details and discharge arrangements with and to AXA Insurance Singapore Private Limited. I/We agree that a copy of this consent shall have the validity of the original.

[Customer’s Data Privacy Consent] In connection with my/our and/or the claimant’s claims, I/We give consent for AXA Insurance Singapore Private Limited (“AXA”) and their respective representatives or agents to collect, use, store, transfer and/or disclose the information (including that provided by sources other than myself) concerning me/us and/or the claimant, to or with all such persons (including any member of the AXA Group or any third party service provider, and whether within or outside of Singapore and the Policyholder when claiming under a Group Policy) for the purpose of enabling AXA and their respective representatives or agents to provide me/us and/or the claimant (where applicable) with services required of an insurance provider, including the evaluating, processing, administering and/or managing my/our and/or the claimant’s claims or the Policyholder Group Policy(ies) with AXA (as the case may be), and for the purposes set out in AXA’s Data Use Statement which can be found at (“Purposes”).

F. Documents Required for Claim Assessment

Below is a list of minimum documentation required to process your claim. In certain circumstances, additional information may be required in order for further confirmation.

Documents Required (Please tick against the documents you have submitted)

Important :

  • Give immediate notice to the police.
  • To the extent allowed by law, retain all monies and other assets due to the Employee(s) and such monies or assets will be deducted from the claim.

G. Final Steps

Upload Supporting Documents

Please note: Total file size should not exceed 3MB.
Please only upload files that end in types: .xls, .xlsx, .doc, .docx, .jgp,.gif, .png, .jpeg, .pdf, .txt
Please attach the relevant supporting documents with your claims submission to expedite claim processing.

Please type what you see in the image:

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Please review and ensure all details are accurate before you proceed.

Thank you for your online Fidelity Guarantee Claim notification. Our claims officer is reviewing your submission and will update your claim status in 14 days' time. Please quote our reference number when corresponding with us.
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AXA Contact Info
Tel: 1800 880 4888 (Within Singapore) / +65 6880 4888 (International)
Fax: +65 6880 4740
8 Shenton Way, #27-01/02 AXA Tower, Singapore 068811

AXA Customer Centre is located at #B1-01

Operating Hours: 9:00am – 5:30pm (Monday – Friday)