CLAIM FORM - EQ TRAVEL. Section 1 - Particulars of Insured. Section 2 - Details of Incident/Loss/Illness (must be completed)

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1 CLAIM FORM - EQ TRAVEL Agency: Policy No.: Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of liability on the part of EQ Insurance Company Limited. Documents required for ALL types of claims: Original Certificate of Insurance. Tour operator s final booking invoices, airline ticket counterfoil(s) / boarding pass(es). Copy of your actual itinerary of trip. Copy of your insurance policy (if applicable). Section 1 - Particulars of Insured Name of of Insured: Address: Postal Code ( ) Contact No.: (Home) (Office) (Mobile) NRIC / Passport No. : Date of Birth: Sex: Male Female Occupation: Are you GST registered at the commencement of the insurance: Yes No Name of of Insured Person: Section 2 - Details of Incident/Loss/Illness (must be completed) Please advise to whom the settlement monies shall be paid (Insured / Insured Person): Please provide full details of the incident, loss or illness: Place where the incident, loss or illness occurred: Do you have other policies covering you in respect of this incident? Yes No If yes, please provide details (name of insurance company, policy number and type of policy): 1

2 Section 3 Details Of Medical/Evacuation and other Related Expenses (Please tick the relevant box) Medical, Dental & Other Expenses Emergency Medical Eavacuation Compassionate Visit By Relative/Friend Hospital Allowance Repatriation Expenses Child Help/ Others Date of accident or onset of illness: Number of days of hospital stay: Amount of claims: Name and address of your usual attending doctor: Have you ever suffered a similar condition or a recurrence of a previous illness or injury? Yes No If yes, please specify: Medical report advising nature and cause of injury / sickness (at the insured s expense) Original medical bills of the full amount of the claim If hospital allowance benefit is being claimed, please submit a letter from the hospital confirming the admission date and date of discharge Death certificate and Burial / Cremation permit (if death occurs) Original bills incurred for accommodation and transportation (for Compassionate Visit and Child Help claims) Section 4 Details of Travel Delay/Missed Flight Connection/Overbooked Scheduled Public Conveyance/Hijacking (Please Tick The Relevant Box) Travel Delay Missed Flight Connection Overbooked Scheduled Public Conveyance Hijacking Original Flight or Transportation Details Date: Time: Place of Departure: Flight No./Transportation Details: Re-Scheduled Flight or Transportation Details Date: Time: Place of Departure: Flight No./Transportation Details: Written confirmation from operator(s) of the scheduled public conveyance stating reason for the delay and the duration of delay (number of hours) Original receipts for meals, accommodation or refreshment expenses incurred if not provided for or compensated by the airline or carrier or other third party (for Missed Flight Connection and Overbooked Scheduled Public Conveyance Claim) Section 5 Details of Delayed Baggage Flight Details Arrival Date: Arrival Time: Departure/Arrival: Flight No.: Flight Details Arrival Date: Arrival Time: Departure/Arrival: Flight No.: Written confirmation from operator(s) of the scheduled public conveyance stating reason for the delay and the duration of delay (number of hours) Original receipts for meals, accommodation or refreshment expenses incurred if not provided for or compensated by the airline or carrier or other third party (for Missed Flight Connection and Overbooked Scheduled Public Conveyance Claim) 2

3 SECTION 6 Please tick the relevant box Baggage & Personal Effects Personal Money & Travel Documents Date of Loss: Did you report the loss to the police, airlines, handling agents or others: Yes No If yes, please specify to whom: Date of reporting: If the loss or damage occurred whilst the baggage was in transit, or otherwise in the custody or control of others, have any steps been taken to claim against these persons? If yes, please specify and attach any correspondence and advise outcome of your claim against them. If no, please state reason(s). Details of Items(s) Lost or Damaged Item(s) lost or damaged (including make/model/serial no. etc.) Place of Purchase Date of Purchase Purchase Price Amount of Claim Details of Money Lost Amount (S$) Amount in Foreign Currency Amount In Traveller s Cheques Total Amount of Claim Original purchase receipt or copy of warranty card of lost/ damaged item Photograph of damaged baggage/ item Property Irregularity Report (if baggage was lost or damaged by an airline or carrier) Police Report (translated into English) Original receipts for replacement of lost items Documents stating the amount of compensation from airlines or other sources SECTION 7 Loss of Deposit/Curtailment (Please tick the relevant box) Loss of Deposit or Cancellation Curtailment When and where was your travel package being booked? Intended Date of Departure: Please state reason(s) for cancellation or curtailment of Trip/Travel: Date of Cancellation/Curtailment: Amount paid by you: Amount recovered/refunded to you Amount of Claim: Loss of Deposit or Cancellation: If due to own injury/ illness, please submit a written advice from doctor (at the insured s expense). If due to next-of-kin s death/ injury/ illness, death certificate or attending doctor s written advice respectively is required (at the insured s expense). Document(s) confirming relationship if cancellation was due to next-of-kin s death/ injury/ illness. Original cancellation invoice from tour operator stating the amount of refund. If there is no refund, please provide us with the original air tickets for record. Documents confirming travel agent s bankruptcy/ insolvency (if applicable). Curtailment: Original letter from tour operator stating the amount of refund. If due to own/ injury/ illness or that of travelling companion, please submit written advice or certificate from the overseas attending doctor confirming their advice for you or your travelling companion s return to Singapore. If due to next-of-kin s death/ injury/ illness, death certificate or doctor s written advice respectively is required (at the insured s expense) Document(s) confirming relationship if curtailment was due to next-of-kin s death/ injury/ illness. 3

4 SECTION 8 Details Of Personal Accident/ Permanent Total Disablement Date of Accident: Place of Accident: Cause of Injury: Nature of Injury: Name of Attending Doctor: Address of Registered Medical Institution that you were admitted to: Have you ever suffered a similar condition or a recurrence of a previous illness or injury? Yes No If yes, please specify: Death Certificate and Burial/ Cremation Permit (in respect of death claim) Letter of Probate or Letter of Administration (in respect of death claim) Medical report (for permanent disablement or loss of limb(s) or sight) Police report (for any transport related accident case) SECTION 9 Personal Liability Date of Accident: Place of Accident: Names & Addresses of all Witnesses of the Incident: Name & Address of Person(s) who caused or who was/were responsible for this incident: Name & Address of Third Party Claimant(s), if any: Please advise the extent of damage to property or bodily injury: Has any claim been made upon you? Yes No If yes, what is the amount claimed? Was there a police report made? Yes No If so, when was it made? Copy of third party s claim/ demand letter Photographs of damage Repair quotation (if any) Police report (if available) SECTION 10 Rental Vehicle Excess Date of Accident: Location of Accident: Excess Amount to be Claimed: Copy of the rental agreement and repair invoice Documentary evidence of the amount if excess or deductible paid Copy of the Police Report made in the country where the accident occurred Copy of the Motor Insurance Policy for this rental vehicle Photograph of damage SECTION 11 Home Guard Date of Fire: Location of Fire: Are you the sole owner of the Property lost or damaged? Yes No Amount to be Claimed: Copy of the Police Report Original purchase receipt(s) of lost/ damaged items (if available), or merchant s price list of identical items lost/ damaged Photograph(s) of damaged items (if available) Quotation for repair/ replacement 4

5 Section 12 Personal Data Collection Statement To evaluate, process and administer this application or transaction, it is necessarily for us to collect, use, disclose and/or process your personal data or personal information about you. Such personal data includes information collected in this form, or in any document provided, or to be provided to us by you or processed by us, or from other sources. A. Purpose of Collection The personal data belonging to you and your insured/s may be collected, used and disclosed for the purposes of: a. carrying out identity checks; b. deciding whether to insure or continue to insure you and your insured persons; c. providing advice for product recommendation based on your profile; d. processing any claims under your policy, including the settlement of claims and any necessary investigations relating to the claims; e. communicating on any matters relating to the services and/or products which you are entitled to under this policy; f. responding to your inquiries or instructions and providing ongoing services, under your policy; g. making or obtaining payments and recovering any debt owed to us; h. detecting and preventing fraud, unlawful or improper activities; i. conducting market research and statistical analysis; j. coaching employees for customer service quality assurance; k. reinsuring risks and for reinsurance administration; and l. complying with all applicable laws, including reporting to regulatory and industry entities. B. Disclosure of Data The personal data belonging to you and your insured/s may be disclosed for the purposes set out in Section A above to the parties below: a. Third party service vendors, suppliers, agents, reinsurers, or intermediaries; b. Medical Professionals and Institutions; c. Local or overseas service third party vendors that provide us with services such as printing, mail distribution, data storage, data entry, marketing and research, disaster recovery or emergency assistance services; d. Debt collection agencies; e. Dispute resolution parties; f. Parties that assist us to investigate, administer and adjudicate claims; g. Financial institutions; h. Credit reference agencies; i. Industry associations; and j. To any regulatory, government and statutory body to comply with applicable, laws or regulation or upon their valid request. C. Personal Data Access and Amendments You can request access to your personal data collected by us, and to make any corrections to your personal data so as to keep it updated. We may charge you a reasonable fee for providing you with the service. D. Withdrawal Option of the collection and use of your personal data You may make your request to withdraw your consent, access or correct your personal data by writing to: The Data Protection Officer, EQ Insurance, 22 Gemmill Lane, Singapore Alternatively, you can to dpo@eqinsurance.com.sg. Neither EQ Insurance nor any of its employees shall be liable for any loss or damage suffered by you or any user as a result of any disclosure of any personal data which you have consented to us and/or any of its employees disclosing. Altering on this Personal data collection statement is strictly prohibited. Any attempt to do so will be of no effect. Section 13 Declaration And Authorisation By Insured (Must Be Completed) I hereby declare that the information stated on this form is true and correct to the best of my knowledge and belief. I hereby authorise any hospital, doctor, person(s) or organisation(s) who has/ have attended to me for any reason, to disclose to EQ INSURANCE COMPANY LIMITED or its authorised representative, any and all information with respect to any illness or injury and to provide copies of all hospital or medical records/ certifications, consultation, prescription or treatment, including earlier medical history. A photocopy of this authorisation shall be considered as effective and valid as the original. Signature of Insured (Please endorse with company stamp, if applicable) Name of Insured : NRIC/Passport No. : Date : EQ Insurance Company Limited, 22 Gemmill Lane, Singapore Tel: Fax: marketing@eqinsurance.com.sg Website: (Co. Reg N) 5