New Claim Notification


Important Notice: 1) This form is provided for online submission on a without admission of liability.
  2) Claim submitted are subjected to the Terms and Conditions of the policy.
  3) If you are submitting a Personal Accident claim below S$200.00, we do not need you to submit your original supporting document(s) to us through mail. All you need to do is to scan & upload your supporting document(s) (example: Clinic / Hospital Tax Invoice) before clicking the "sent" button.

CLAIM SUBFOLDER
Claim Type General Non-Motor (NM)
Handling Insurer Etiqa Insurance Pte Ltd
Policy Class Travel
Policy No.
If you keyed in a COVER NOTE NO., check here  		Policy Coverage Date From:
To:
Accident/Loss Date   Time
Contact Person Contact No.

CLAIM LOSS DETAILS
Initial Estimation (S$)
Acc/Loss Place
Acc/Loss State Acc/Loss City
Nature of Accident / Illness (or offical cause of death)
Description of Accident/Loss
(Maximum. 2048 characters)

INSURED DETAILS
  
Birth Date  Gender 
Marital Status
E-mail
Address 1
Address 2
Country
State
City
Postcode
Mobile Phone No.
Type NOPHONE here if no insured h/phone
Office Phone No.
Other Phone No
Fax No.
Occupation
CLAIMANT DETAILS
   Same as Insured   Claimant is Injured
Birth Date  Gender 
Marital Status
E-mail
Address 1
Address 2
Country
State
City
Postcode
Mobile Phone No.
Office Phone No.
Other Phone No
Occupation
Date Employed
INJURED DETAILS
Birth Date  Gender 
Marital Status
Relationship to Claimant
Occupation
Employer
 

ADMISSION DETAILS
Hospital/Clinic/Sinsehs
Admission Type Surgery Date
Admission Date Discharge Date
Doctor's Name









Declaration
By submitting this eForm online, I hereby confirm that the information given in this eForm are true and correct to the best of my knowledge and belief and that no other material information has been withheld nor any relevant circumstances omitted.

I/We further declared that the information submitted in this eForm or held by Etiqa Insurance Berhad whether contained in my/our insurance application or otherwise obtained may be used and disclosed to your authorised staff, associated individuals and/or companies or any independent third parties (within or outside Singapore) who will provide claims administrative, advice and/or information or claims services in relation to my/our claim. I/We understand my/our data that may also be used for audit, business analysis and reinsurance purposes. By submitting this eForm online will signify this consent.











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