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File A Claim

File A Claim
File A Claim

Golf Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

B. Claimant Details

Full Name

NRIC/FIN No.

Membership Number

Mobile No.

Email

C. Loss Details

Place of Loss/Damage

Date of Loss/Damage

Time of Loss/Damage

Describe fully how it occured and the nature of loss or damage

D. Particulars of Claim

Articles actually lost or stolen are to be described first.
Articles which have been damaged must also be described and shown after lost or stolen article descriptions.

Description of lost/damaged item(s) (Brand, make & model)

Nature & Extent of Damage

Place of Purchase

Date of Purchase

Purchase Price (SGD)

Cost of Repair or Replacement (SGD)

Deduction for age, use and/or wear & tear (SGD)

Amount Claimed (SGD)

Article #1
+ Add another entry

Total Amount (SGD)

E. Hole-In-One Achievement

Date Hole-In-One was achieved

Golf course at which Hole-In-One was achieved

F. Personal Accident and Medical Expenses

Nature of Injury Sustained

Body Part Injured

Amount Claimed (SGD)

G. Liability to the Public

Details of Third Parties

Name

Address

Nature of Injury/Extent of Damage

Detail #1
+ Add another entry

Has a claim been made upon you in respect of this accident?

If yes, what is the amount claimed (SGD)

Have you in any way admitted liability?

If yes, please state reason:

Was the accident contributed to or caused by negligence on the part of the third party?

If yes, in what way was the third-party negligent?

H. Other Insurance/Information

Is there any other insurance covering this incident?

If Yes, please state Name of Insurance Company

Policy Number

I. 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

J. 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 http://www.axa.com.sg (“Purposes”).

K. 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)

L. 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 Golf 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)