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File A Claim

File A Claim
File A Claim

Windscreen Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

B. Claimant Details

Full Name



Mobile No.

Correspondence Address

C. Circumstances of Windscreen Damage

Type of Policy

Vehicle Number

Date of Loss/Accident

Country of accident?

Tell us how it happened

Which glass sustained damage? You may select more than one*

Did you know?

You can get $50 cash when you choose to repair your windscreen instead of replace it!

Do you intend to repair or replace your windscreen?

Interested in Mobile Repair Service

Please select your damage:

Name of Workshop

D. 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.

[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”).

E. 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.

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 Windscreen Claim notification. Our claims officer is reviewing your submission and will update your claim status within the next 2 business days. Please quote our reference number when corresponding with us.