FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies

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1 FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies 18 Cross Street #11-08 China Square Central Singapore Telephone: Facsimile: Unique Entity No. S83FC3361G OVERSEAS / BUSINESS TRAVEL INSURANCE CLAIM FORM IMPORTANT NOTE The Insured is requested to state as fully and as accurately as possible the information asked for hereunder in order to expedite claim processing. Please ensure that all relevant supporting documentation is submitted within 30 days from date of return with this claim form. If any information or documents are currently not available, please let us know and state the reason(s). Any documentary proof or reports required by the Company shall be furnished at the expense of the Policyholder or Claimant. Thank you for your assistance to enable us to expedite claim processing. Our acceptance of this Form is not in itself an admission of liability on the part of the Company. A POLICYHOLDER POLICY TYPE: Personal Travel: Single Trip Annual Business Travel Secondment 1 Employer / Policyholder Policy No. 2 Address 3 Tel/Mobile EMPLOYEE / CLAIMANT Marital Status Married Single 4 Employee Sex F M Age 5 Home Address Nationality & NRIC/Passport No. 6 Occupation 7 Commencement date of employment Tel/Mobile 8 If employed less than 12 months, state name of prior medical insurer 9 ADDITIONAL INFORMATION FOR OVERSEAS POSTING / SECONDMENT POLICY (Questions 9 to15 only) 10 Home / Country of Residence 11 Commencement Date of Posting 12 City / Country of Posting 13 Insured Person (if not Employee) 14 Relationship to Employee 15 NRIC/ Passport No. 16 Age / Date of Birth 17 Insured Person s prior medical insurer, if insured less than 12 months under this policy 18 Are there any other insurance which would cover this loss? Yes No 19 Name of Insurance Company & Policy No. If Yes, please submit claim to the other insurance company and provide copies of policy and completed claim form for our review. B CLAIM TYPE Please tick box accordingly Flight Delay Medical Expenses Trip Cancellation Loss / Damage to Personal Effects Baggage Delay Missed Connection Trip Curtailment Loss of Money / Documents Baggage Loss Personal Insurance Personal Liability Permanent Disablement / Accidental Death Others 1

2 C DETAILS FOR ALL CLAIMS (Please attach a separate sheet if space below is insufficient) Date and Time Place NOTE: If you are claiming for MEDICAL EXPENSES incurred, the doctor s diagnosis and/or the cause or reason for seeking medical treatment is crucial information and must be stated below. This information, if missing, will cause delay to your claim. Additional details are required in Section F. 2

3 D. TRAVEL DETAILS PLEASE COMPLETE THIS SECTION FOR CLAIM INVOLVING TRAVEL OVERSEAS Purpose of Trip Business Business cum Personal Vacation Personal Vacation Home Leave Duration of Trip From To You can omit the following if a copy of your travel itinerary or e-ticket is submitted with this claim form 1. Departure Airport Carrier / Flight No. Date and Time 2. Transit Airport, if any Carrier / Flight No. Date and Time 3. Arrival Airport Carrier / Flight No. Date and Time E. TRAVEL DELAY / BAGGAGE DELAY CLAIM INFORMATION 1. FLIGHT DELAY Airport Delayed Flight No. Date & Time 2. MISSED CONNECTION Airport Delayed Flight No. Date & Time 3. BAGGAGE DELAY / LOSS Airport Place of Receipt Date & Time F. MEDICAL / PERSONAL ACCIDENT CLAIM INFORMATION Have you ever suffered this or a similar condition or was this recurrence of a previous illness or injury? If yes, please provide details, including dates Dates and Details Yes No Names and addresses of usual attending Physician(s): For Accident, names and addresses of witnesses, if any: Name and address of the Police Station where the report was lodged. A copy of the report should be attached to this form. If report was not lodged, please advise reason. L:\SNG-Claims\1 - A & H\ABL CLAIM FORMS\OverseasBizTravelClaimForm with PDPA dated 14 July 14.doc 3

4 G. CLAIM QUANTUM FOR ALL CLAIMS PLEASE STATE BRAND / MODEL NO. FOR LOST PROPERTY OR BAGGAGE CLAIMS TO AID CLAIM ASSESSMENT Purchase Date or Consultation Date Description of Lost/Damaged Items or Medical Services /Treatment Original Price Paid or Consultation Fees Replacement or Repair Costs Amount Claimed Please attach a separate list if space is insufficient above We/I understand, acknowledge, agree and consent that: PERSONAL DATA PROTECTION (a) Federal Insurance Company, may/is permitted to collect, use, disclose and/or process our/my personal data/personal information set out in this form and any other personal information provided by me or possessed by Federal Insurance Company (collectively the Personal Information ) and disclose and transfer such Personal Information to its lawyers/law firms, the Monetary Authority of Singapore and any relevant government agency/authority (such as the police), for the purpose(s) of : (i) (ii) (iii) (iv) (v) processing, handling and/or dealing with my claims including the settlement of the claims and any necessary investigations relating to the claims; investigating the accident and/or my claims; carrying out and/or dealing with my instructions or responding to any enquiries by us/me; administering my claims (including the mailing of correspondence, statements, invoices, reports or notices to me, which could involve disclosure of certain personal data about us/me to bring about delivery of the same as well as on the external cover of envelopes/mail packages); and/or complying with applicable law in administering, processing, handling and/or dealing with us/my claims. (collectively the Purposes ) (b) (c) Federal Insurance Company s lawyers/law firms, may/are permitted to collect, use, disclose and/or process my Personal Information for one or more of the above Purposes; and our/my Personal Information may/can be disclosed by Federal Insurance Company for one or more of the above Purposes to: (i) its third party service providers, related bodies corporate, contractors or agents (including their lawyers/law firms), which may be sited outside of Singapore; (ii) any third party in connection with claims made by or against or otherwise involving us/me in respect of any products or services provided by Federal Insurance Company; L:\SNG-Claims\1 - A & H\ABL CLAIM FORMS\OverseasBizTravelClaimForm with PDPA dated 14 July 14.doc 4

5 DECLARATION We/I hereby declare that to the best of my knowledge and belief, the statements and answers in this form are true and correct in every respect. We/I understand that any person who knowingly and with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. We/I also hereby authorise any hospital, physician, or other person who had examined me or attended to me, to disclose when requested to do so by Federal Insurance Company or its authorised representative, any and all information with respect to any illness, or injury, medical history, consultations, prescriptions or treatment, or incident or copies of all hospital or medical records or any records. A photocopy of this authorisation shall be considered as effective and valid as the original. PAYMENT OF CLAIM Subject to Policy terms and conditions, I/we hereby authorise and request Federal Insurance Company to pay the benefit due in respect of this claim to: Note: Payment is made in the form of Singapore Dollars cheque, regardless of the Insured Person/Claimant s Home Country or Country of Residence/Secondment or the nationality or location of the Policyholder.. Name & Signature of Insured Person and/or Claimant Name, Signature & Designation of Policyholder s Representative / HR Personnel & endorsed with Company stamp Date Date L:\SNG-Claims\1 - A & H\ABL CLAIM FORMS\OverseasBizTravelClaimForm with PDPA dated 14 July 14.doc 5

6 FEDERAL INSURANCE COMPANY OVERSEAS / BUSINESS TRAVEL INSURANCE CLAIM SUPPORTING DOCUMENTS The list of supporting documentation stated below is not exhaustive and we reserve our right to request any additional information/documentation, as necessary. The submission of an incomplete form or insufficient information or supporting documents may delay the processing or result in the denial of your claim. To facilitate consideration of your claim, please ensure you submit the essential supporting documents together with the completed claim form as soon as possible. We will contact you if additional documents or information are necessary. Please tick documents attached: For all Travel Claims submitted Flight Delay or Missed Connection Completed claim form (Note: for Business Travel and Secondment Policies, the Claim Form must be endorsed with company s stamp and signed by an authorised company s representative) Original air tickets and boarding passes for the entire trip Copy of travel itinerary for the entire trip Airline written confirmation stating reason(s) for delay and the length of delay Airline s letter or any documents confirming date and time of re-scheduled flight Original invoices/receipt(s) for additional expenses for accommodation and travel (if applicable) Airline s letter stating compensation (if applicable) Baggage Delay Loss of Money, Passport or Documents Loss of or Damage to Baggage or Personal Effects Trip Cancellation or Trip Curtailment Medical Expenses Airline baggage tag Airline Property Irregularity Report stating date / time of delay Documents confirming date / time baggage was returned Airline s letter stating compensation (if applicable) Original copy of police report Original invoices / receipts for expenses incurred to replace lost documents Documents to substantiate claim quantum Original copy of police report Original property irregularity report from airline, airport authority or hotel confirming loss or damage Original airlines letter stating compensation for lost / damaged items Original invoice/receipt of damaged or lost items Photo of damaged item and repair quotation (if any) Repair invoice/receipt of damaged item with details of damage sustained and repair work done If item is replaced, copy of invoice / receipt of replacement item Certified true copy of death certificate and documents (e.g. birth certificate, marriage certificate) to prove relationship between Insured Person/Claimant and deceased Medical report and/or other documents to substantiate the reason for trip cancellation or trip curtailment Original invoices/receipts showing any pre-paid costs or deposits made and not refunded Original documentation/receipts indicating the additional travel and/or accommodation expenses incurred Original medical bills/receipts Original medical report or certification from the attending Physician stating diagnosis or reason for treatment Original copy of police report and newspaper report, if available Original medical report Permanent Disablement / Accidental Death Personal Liability Additional documents for Accidental Death Claim: Certified true copy of death certificate, coroner s report or autopsy report (if any) Certified true copy of claimant s identification documents (such as identity card, passport, marriage or birth certificate) to prove relationship between Claimant and Insured Person Legal documents (such as certified true copy of Grant of Letters of Administration or Grant of Probate) where and when required by law, must be submitted at the claimants expense Copy of police or accident report, if any Copy of letter of demand from third party and writ, if any Others L:\SNG-Claims\1 - A & H\ABL CLAIM FORMS\OverseasBizTravelClaimForm with PDPA dated 14 July 14.doc 6

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