Liability Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

Telephone No.

Do you have other insurance covering you in respect of this accident? If yes please provide details

Yes No

Is your Company GST Registered?

Yes No

B. Claimant Details

Full Name

Tick if Claimant is policy holder

Telephone No.

C. Loss Details

Amount Claimed (SGD)

Details of the Claim

Is the claimant in your direct employment? If not please provide the name and address of direct employer

Yes No

Date of Accident

Time of Accident

Location of Accident

Description of Accident

When did you receive notice of the accident and from whom? If in writing, please attach a copy to this form

From whom did you receive notice of the accident?

Describe in detail, your immediate actions taken upon notification of the incident.

How could you have prevented the incident?

State name of contractor/Distributor/Retailer involved in the incident and attach a copy of the contract agreement

State in your opinion whether you are liable for the incident and reasons

Please provide name and address of every witness and every other person who was present

Name

Address

Witness #1

+ Add another entry

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 Pte Ltd. 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 Pte Ltd(“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”).

I, the claimant agree to abide by the terms & conditions.

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)

Police Report/Incident Report

Colour photos showing the damaged property &/or CCTV footage showing circumstances of incident

Technical report from repairer on the cause and extent of the damaged property

Tenancy and/or Contract Agreement

Original repair/replacement invoices/receipts

Important :

Please do not admit liability without the written consent of AXA
Please forward to us all correspondences including writ of summons you may receive from any third party/parties or their representatives immediately and unanswered.

G. Final Steps

Upload Supporting Documents

Please note: Total file size should not exceed 3MB.
Please only upload files that end in types: .png, .gif, .jpeg, .jpg, .pdf, .doc
File name must only contain alphanumeric characters, hyphen, dash and no spaces.
Please attach the relevant supporting documents with your claims submission to expedite claim processing.

Other

Please type what you see in the image:

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

File A Claim

A. Policy Information

B. Claimant Details

C. Loss Details

D. Bank Account Details

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

F. Documents Required for Claim Assessment

G. Final Steps

Confirmation content comes here