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File A Claim

File A Claim
File A Claim

Work Injury Compensation Claim Form

A. Policy Information

Policyholder's Full Name

Policy/Certificate No.

Email

Telephone No.

Total no. of Employees

Is your Company GST Registered?

B. Claimant Details

Full Name

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

No. of working days per week

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

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?

Please provide details:

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

Please provide details:

Type of Medical Treatment

Name of Hospital/Clinic taken to

Has the claimant returned to work?

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 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”).

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)

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.

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 Work Injury Compensation 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)