FEDERAL INSURANCE COMPANY SINGAPORE One of the Chubb Group of Insurance Companies

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1 FEDERAL INSURANCE COMPANY SINGAPORE One of the Chubb Group of Insurance Companies 18 Cross Street #11-08 China Square Central Singapore Telephone: Facsimile: Unique Entity No. S83FC3361G CLAIM NOTIFICATION FORM The Insured is requested to state as fully and as accurately as possible the information asked for hereunder and to return the form immediately to the Company. Acceptance of this Form is not in itself and admission of liability on the part of the Company. Please indicate with a tick ( ) for the nature of the loss you are reporting. Property Damage General / Third Party Liability I. Preparer s Information Your Name: Office / Mobile Tel: Address: Date Submitted: II. Insured s Information Insured Name: Address: Office / Mobile Tel: Business: Contact Person: Address: Policy No: Period: To III. Other Insurance Is there other insurance which applies to this loss? Yes No If YES, please provide the following information: Insurance Company & Policy # Policy Period Kind of Coverage Sum Insured Part A Details of Loss or Damage Date of Loss: Date of discovery: Time of Loss: (If known) Estimate of Loss: Exact Location where Loss or Damage Occurred: Are you the sole owner of the property lost or damaged? Yes No Has this any loss or damage of a similar nature occurred before? Yes No Page 1

2 If YES, please provide brief details: Part B Describe how the Loss occurred (What happened? How?) What Police or other Authority contacted: Name of Official reported to: What, if any, police action was taken: Part C Nature & extent of Loss or Damage including cost details (Please itemise) C *Note: If your notification relates to a Third Party loss only, Part C does not need to be completed. C Describe how the loss occurred (What happened? How?) Full Description of Articles Lost or Damaged Date Purchased Price Paid Current Replacement or Repair Costs Amount Claimed Total Claimed: Page 2

3 Please Note: 1. If you have additional articles to enter, please insert more lines or use a separate sheet. 2. Receipts showing date, price and place of purchase of the articles lost or damaged should accompany this form whenever possible. This will greatly facilitate and expedite claim processing. 3. Insured must promptly take all possible steps to trace/recover the property lost and in the case of theft to discover and punish the guilty party/parties. 4. In the case of damage, an estimate to repair should be submitted. If the article is not repairable, a letter or statement from repairers or suppliers to that effect should be submitted. All salvage must be retained. Part D Report of Third Party Injury and/or Property Damage (Particulars of incident likely to result in third party personal injury and/or property loss or damage claims) NB. You may skip this section if this notification or claim does not involve third party injury or property damage. Please be reminded that under no circumstance should you admit liability or make any offer/settlement or enter into any correspondence with third party in connection with any incident, which may result in a claim under your policy. All written communications from other parties must be forwarded unanswered immediately to your broker or to Federal Insurance Company. 1. State name, address and contact numbers of person(s) injured or owner(s) of property lost or damaged. Provide same details of parents or legal guardian if injured person or owner of property is a minor (stating the minor s age and full name). 2. State name, address and contact details of every Witness and any person who was present. 3. State nature of third party personal injury or property loss or damage sustained. 4. Estimated Loss: S$ 5. If applicable, details of the product(s) alleged to have caused the injury/damage with full details of any alleged defects, identity of distributor/retailer and any other comments. Page 3

4 6. If this claim is in respect of any alleged faulty or defective product, please advise whether you have previously had any claims made against you in respect of this particular product. If so, please give details. 7. Has a Third Party claimant and/or its representative(s) made a report of personal injury and/or property damage to you? Yes No 8. If YES, by whom and when? Attach all relevant correspondence to this form. 9. Have any claims been made against you? Yes No 10. If YES, please provide details and attach all relevant Third Party correspondence to this form. 11. Have you admitted responsibility in any way? Yes No 12. In your opinion, was Third Party responsible for the accident? Yes No 13. What duty did you owe injured party or owner of damaged property? Part E Action taken to minimise loss and/or prevent recurrence Page 4

5 Part F Declaration 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. 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. Part G Personal Data Protection We/I understand, acknowledge, agree and consent that: (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; Signature: Date: Name: Designation: You are reminded to submit the completed form together with supporting documents such as receipts, police reports, and/or other relevant documents/photographs as soon as possible to Federal Insurance Company or your broker for claim processing. If any detail or information is not readily available, please do not delay despatch of this form, but submit further details at a later date. Any new information subsequent to the date of this notification must be forwarded as soon as it comes to your knowledge. Should you have any question, please contact any one of our claims personnel: Steven Lim Bernadette Yeo DID (65) or via address: DID (65) or via address: Page 5

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