AVIVA LTD 4 Shenton Way #01-01, SGX Centre 2, Singapore Telephone: Fax: Company Reg. No K

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1 PERSONAL ACCIDENT CLAIM - CLAIMANT S STATEMENT Dear Claimant We re sorry to receive notice of the Life Assured s injury. To enable us to process your claim, please follow the instructions provided below: Documents Required: INSTRUCTIONS HOW TO FILE A PERSONAL ACCIDENT CLAIM 1) Accident Claim Form: Section 1 Claimant s Statement 2) Accident Claim Form: Section 2 Physician s Statement (to be completed by the attending physician) 3) Clinical Abstract Application Form (refer to Important Note (5) below) 4) Copy of the Detailed Inpatient Discharge Summary and any diagnostic reports, laboratory evidence and any relevant hospital reports that are available. 5) Original Medical Certificates if claim is for Weekly Indemnity. Else, copies of all medical leave certificates. 6) Original Hospital Bills if claim is for Medical Expense 7) Toxicology Report 8) Newspaper Clipping (if any) 9) Police Investigation Report (if any) 10) Copy of the NRIC/FIN or Passport of the Life Assured 11) Copy of the NRIC/FIN or Passport of the Policy Owner, if different from Life Assured 12) Copy of the claim settlement letter and payment voucher if there was a reimbursement from another insurer or Employer (if any) 13) Proof of Policy Owner s relationship with Life Assured as follows (where applicable): Policy Owner Documents required (Certified True Copy) Spouse Marriage Certificate of Policy Owner Children Birth Certificate of Life Assured Parent Birth Certificate of Life Assured Sibling Birth Certificate of Life Assured and Policy Owner IMPORTANT NOTE: 1. All questions in the Claimant s Statement must be fully and truthfully answered. We reserve the right to pursue for any documents that are not mentioned above if they are deemed necessary. 2. These said documents shall be in the forms as prescribed by Aviva Ltd and shall be furnished at the expense of the Claimant(s). 3. The cost of the Physician s Statement and/or medical evidence shall be borne by the Claimant(s). 4. For Physician s Statement or reports to be obtained from hospitals, specific Clinical Abstract Forms may be used. Please refer to the respective hospital s website for details. For clinics, please use Aviva s Clinical Abstract Application Form. 5. All documents submitted must be in English. Any document that is not in English must be accompanied by an English translated copy of the document made by a certified translator/interpreter. In addition, a certificate stating the proficiency of the translator in the language being translated must also be submitted. 6. If the Policy has been assigned, original Assignment Deed is required. 7. All claims required documents can be submitted to Aviva Ltd through the Aviva s Advisors. Alternatively, you may submit the claim personally to our Customer Service Centre. Personal Accident Claim Form Jun2014 Page 1 of 5

2 CLINICAL ABSTRACT APPLICATION To whom it may concern: Dear Sir/Madam Please furnish AVIVA LTD with a detailed medical report on: (Name of Patient) NRIC / BC This report is required for insurance purposes. Upon receipt of this application from AVIVA LTD, you may furnish a detailed medical report (together with histology report, laboratory results, etc.) whether for use in connection with litigation or for other legitimate purposes. I agree that a copy of this authorisation form shall be considered as effective and valid as the original. Signature of Patient Signature of Next-Of Kin (if Patient is above 21) (if Patient is below 21) Name : Name : Address : Address : NRIC No : NRIC No : Date : Date : Relationship to Patient : Personal Accident Claim Form Jun2014 Page 2 of 5

3 PERSONAL ACCIDENT CLAIM - CLAIMANT S STATEMENT IMPORTANT: Please refer to the instructions under How to file a Personal Accident Claim in page 1 before completing this form. 1. Claimant will be responsible for the accuracy and integrity of the information provided. Failure to provide details or disclose all relevant information may delay the claim assessment. 2. The medical reports fees (if any) will be borne by the Assured. 3. Please continue to pay your premium until we have informed you the outcome of your claim. 4. We advise that Aviva Ltd does not admit liability by the mere issue of this or any other form. SECTION 1 To be completed by the Life Assured POLICY NUMBER(S): A. Details of Life Assured Name of Life Assured ID/FIN/Passport/BC No Occupation Date of Birth Marital Status Gender Religion Name and address of Employer Mailing Address Contact No. Name of Assured (if different from Life Assured) ID/FIN/Passport/BC No B. Details of Accident 1) Date & Time of Accident 2) Place of Accident 3) Describe in detail how the accident happened 4) Nature and extent of injuries 5) Was the accident reported to the Police? Yes No If Yes, please provide a copy of the police report. 6) When did you become disabled so as to be prevented from doing any work? 7) When did you return to work? 8) Please give details of your current physical defects or infirmities 9) Have you made any previous claims for Accidental Benefits? Yes No If Yes, please give details. 10) Are you entitled to compensate from any other source? Yes No If Yes, please provide: a) Source: b) Amount Compensated: Personal Accident Claim Form Jun2014 Page 3 of 5

4 B. Details of Accident (continue) 11) Are you insured for Workmen s Compensation or Personal Accident Insurance with other insurance company? Yes No If Yes, please provide: a) Name of Insurance Company: b) Policy No: 12) Details of doctor(s) consulted or hospital(s) admitted for this Injury Name & Address of Doctor Date 1 st & Last Consulted Treatment Provided 13) Details of Life Assured s doctor(s) consulted for any other disorders / conditions Name & Address of Doctor Reason for Consultation Treatment Provided Date 1 st & Last Consulted 14) Have you been hospitalized for condition(s) related to your Injury? Yes No If Yes, please state Name of Hospital Date of Admission Date of Discharge Reason for Hospitalization 15) Is the Life Assured claiming from any other Insurer(s) or other sources in respect of this Injury? Yes No If Yes, please provide the details. Name of Insurer Type of Plan Policy Effective Date Sum Assured Personal Accident Claim Form Jun2014 Page 4 of 5

5 DECLARATION AND AUTHORISATION I/We, hereby declare that the answers given by me/us in this Form are in every respect true and correct and that no material information has been withheld nor any relevant circumstances omitted. I/We further consent to Aviva Ltd seeking information from any clinic, hospital, physician, person, organisation, employer that may be required in connection with this claim and I/We authorise the giving of such information to Aviva. A photocopy of this authorisation shall be considered as effective and valid as the original. I/We consent to Aviva (and Aviva related group of companies) collecting, using and/or disclosing my/our personal data for the processing of the above transaction and such other purposes ancillary or related to the administering of the policy(ies), account(s) and/or managing my/our relationship with Aviva. I/We also consent to Aviva (and Aviva related group of companies) transferring my/our personal data to Aviva related group of companies and/or third party service providers, reinsurers, suppliers or intermediaries whether located in Singapore or elsewhere, for the above purposes. For full details of the purposes of collection, use and disclosure of your personal data, please visit Note: If you are filling up this form on behalf of another person or whereby you are disclosing personal data to us other than yours, you are required to inform such person(s) of the purpose and obtain his/her consent before submitting this form to us. Once you have submitted, you will be deemed to have obtained the necessary consent for us. Signature of Assured:.. Signature of Life Assured *:.. Name of Assured:. Name of Life Assured:..... NRIC/FIN No:. NRIC/FIN No: Address:... Address: Contact No: Date:.. Note: * Signature of Life Assured (if Life Assured is age 21 and above) Personal Accident Claim Form Jun2014 Page 5 of 5

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