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File A Claim

File A Claim
File A Claim

SmartHelper Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

NRIC/FIN No.

Mobile No.

Email

Home Address

Name of Patient (Domestic Helper)

Age

Sex

Date of Employment

Work Permit Number

B. Sickness (This must be answered in full)

Diagnosis

Date Symptoms First Began

Date First Treated

Is the sickness arising from employment?

Has the sickness been treated previously? If yes, please state name and address of Physician.

Date of Last Treatment

Is the sickness due to pregnancy, abortion, sterilization or infertility? If yes, specify condition and approximate date of commencement.

Date of Commencement

Name and Address of Hospital/Clinic:

C. Injury

Date of Loss/Accident

Time of Loss/Accident

Name and Address of Hospital/Clinic:

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. Employer & Patient’s Declaration

I / We confirm that I / We am the patient and the patient’s employer (respectively) and I / We declare that all the particulars given above are to the best of my / our knowledge true and correct. I / We hereby consent to and authorise the medical practitioner involved in the patient’s care to discuss and disclose treatment details, medical history 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. In connection with my / our 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, 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 related parties under this Policy) for the purpose of enabling AXA and their respective representatives or agents to provide me / us with services required of an insurance provider, including the evaluating, processing, administering and / or managing my / our claims or this 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”).

F. 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 Domestic Helper 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)