Work Injury Compensation Claim Form

B. Claimant Details

Full Name

Tick if Claimant is policy holder

NRIC/FIN No.

Mobile No.

Nationality

Date of Birth

Occupation

Date of Employment

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

Yes No

No. of working days per week

5 days 5.5 days 6 days Others, please specify

Average Monthly Earnings (12 months before the accident) (SGD)

C. Accident Details

Date of Accident

Time of Accident

Location of Accident

Is this a project site? If yes please provide Main Contractor name

Yes No

Description of Accident

Description of Injury Sustained (e.g. body part injured, injury type)

Are you satisfied the injured has met with a bona fide accident arising out of his/her employment?

Yes No

Please provide details:

Was the injured under the influence of alcohol or drugs at the time of accident?

Yes No

Please provide details:

Type of Medical Treatment

Inpatient Outpatient

Name of Hospital/Clinic taken to

Has the claimant returned to work?

Yes No

Please provide details:

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)

Medical Certificates

Original Final Hospital/ Medical Bills

Medical Reports/ Inpatient Discharge Summary - if any

Police Report/ Accident Report – for traffic accident claim, etc.

Death Certificate – only for death claim.

Contract agreements if accident occurred at project site

Work Permit

Wage Payment vouchers – 12 month before accident

Wage Payment voucher during medical leave

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.

Other

Please type what you see in the image:

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

File A Claim