Company Reg. No. : 192300014M

20 McCallum Street#09-01 Tokio Marine Centre
Singapore 069046
Tel : (65) 6221 6111 Fax : (65) 6225 9887
Email : tmis@tokiomarine.com.sg
Website : www.tokiomarine.com.sg

Public Liability Claim Form(the company does not admit liability by the issuance of this form)

Fire and GA Claims Department : Fax: 6225 9887

Name of Policyholder :Policy No :Tel No :Address:

Email :
Contact Person :Are you GST Registered? Yes / No

If Yes please fill

GST Registration No.

Details of Accident:

Date :

Time :am/pmPlace :State exactly how the accident happened :Who was to blame? Please provide reasons:If plant and/or machinery are used, please advise:a) Name of person operating it at the material time of accident?
b) Owner of the Plant and/or Machinery?
c) Name of Insurance Company of this Plant and/or machinery
If accident is attributed to defect in your premises or plant, please advise:a) Nature of defect alleged :b) Do you admit the defect alleged : Yes / Noc) If Yes, were you aware of the defect before accident : Yes / Nod) If Yes, what steps did you take to remedy it?

e) Have you order any alteration or repair after the accident? Yes / Nof) Are all statutory obligations observed or complied with? Yes / No
Details of negligent person
Name :

Address :Occupation :Is he/she your employee? Yes / No
If Yes, how long has he/she been employed :Was he given any form of training :Please list witnesses’ names if available:
Name:

Name:

Address:

Address :Relationship to insured:

Relationship to insured:

Particulars of Injured third party:
Name :
Age :Address :Sex: Male / Female

Occupation :Nature of Injury :Was the injured person contributory negligent? Yes / No
In what way was the injured contributory negligent?

Name of third party’s employer :Is third party’s employer your sub contractor? Yes / No
Does his contract include a provision indemnifying you against accidents to his employees? Yes / No
(Please attach copy of contract if available)
If third party employer is your Principal Contractor, does your contract include an indemnity to the Principal Contractor? Ye s / No
(Please attach copy of contract if available)
Particulars of third party’s property damage:Describe property damaged:

Nature and extent of damage :Name of property owner :Address of property owner :Has a claim been made upon you for this accident? Yes / No

If Yes, for what amount?
Please attach listing if necessary.

Declaration: I hereby declare and warrant that all the answers given above to be true. I accept that insurers would be at liberty todeny liability in part or in full if the above written answers are false or inaccurate in any aspect
Notice for Personal Data Protection Policy
By signing this form:i) I/We acknowledge and consent to TMiS collecting, using, processing and disclosing to third party service providers and/orintermediaries, within or outside Singapore, my/our personal data for the purpose of processing and servicing my/ourpolicies/claims;ii) I/We declare and confirm that I/we have obtained the consent of the person(s) and/or nominee(s) named herein, whereapplicable, and that he/she/they has/have authorized me/us to disclose their personal data and to give consent on their behalf
for the above collection, use, process and disclosure; andiii) I/We acknowledge the detailed Privacy Policy Statement, governing the above, posted at www.tokiomarine.com.sg.

Signature of Insured / Date
Importance Notice:
1. The insured is required to furnish the Particulars above as fully and accurately as possible.
2. This form is sent without prejudice to the terms and conditions of the Policy and should not be regarded as a waiver by theCompany of any breach of the Policy Conditions the Insured may have committed.
3. The acceptance of this form is not in itself an admission of liability on the part of the Company
4. If any person has been injured or damage caused to third party vehicle or property, DO NOT admit liability in any way.
5. Communication of any kind you received should be sent immediately and unanswered, to the Company.
Please mail duly completed claim form to:
Tokio Marine Insurance Singapore Ltd, 20 McCallum Street #09-01, Tokio Marine Centre, S’pore 069046.
Fire & GA Claims DeptFax : 6225 9887
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