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

Personal Accident Claim Form
The company does not admit liability by the issuance of this form. The issued form must be completed and returned withinseven (7) days of receipt. No claim can be admitted unless Medical Certificate from a duly qualified and Registered Medical
Practitioner, on the form annexed be furnished at expense of Insured.
Claims Fax No : 6225 9887

InsuredInsured:Age:___
NRIC No:___

Policy No:

Sum Insured:___

Address:Tel No/email:______

Occupation :__Are you self employed? Yes No, If No, state employer’s name and address:____

Do you have any other insurance that will cover this loss? Yes No If Yes, please provide details:
Have you ever made a claim under any PA policy before? Yes No If Yes, state insurer, amount and date:

Details of Accident
Date:

Time:

am/pm

Place:

State particulars of Accident in detail:Inpatient Outpatient

Name of hospital (or clinic) taken to:(Please fill in clinic’s name if not hospitalized)

State names of witnesses to the accident:

Admitted on:

Discharged On:___

State number of days you expect to be necessarily and entirely confined to House or Hospital, by Doctor’s orders as
the sole and direct result of the injuries sustained:

If still confined, state which:

To House:days

To Hospital:days

To House:days

To Hospital:days

Do you expect in any way to attend to any part of your business or work during the above period. If so please
describe as follows:

Declaration
I hereby declare that I am the person referred to in the foregoing particulars, that I have received the injuries before
described by violent, external and visible means. And I do further declare that I have always been uniformly sober
and temperate in my habits, and that I was no way under the influence of drugs or intoxicating liquor when theaccident occurred, and that I have not abstained from business or work, either totally or partially, longer thanabsolutely necessary in consequence of the said injuries, and that such injuries are the sole and direct cause of mydisablement or loss.
I do hereby warrant the truth of the foregoing statements in every respect, and I agree that if I have made or in any
further declaration the Company may require of me in respect of the said accident shall make, any false orfraudulent statement, or any suppression, concealment, or untrue avertment, the Policy shall be void as against theCompany, and my right to compensation absolutely forfeited.
I hereby claim indemnity (compensation) as provided under my Policy as follows:

1) Temporary Partial Disablement:Weeks @per week =2) Temporary Total Disablement

Weeks @

per week =3) Permanent Partial Disablement
4) Permanent Total Disablement
5) Death
Important Notice: The insured person must, in the event of a claim, advise the company as to any other insurance that they ma y
have covering the same risk.
Declaration: I hereby declare and warrant that all the answers given above to be true. I accept that insurers would be at liberty
to deny 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 theirbehalf 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
Name::Date:MEDICAL REPORT - TO BE COMPLETED BY ATTENDING PHYSICIAN
Name of Patient:
NRIC No.:

Profession/Occupation:

Are you the patient’s usual medical doctor?
Have you attended him for any illness or accident before?

Yes
Yes

No
No

Yes

NoIn your opinion, are the injuries sustained in linewith the accident that patient described?

Yes

No

Is the patient now or was he at the time of accident,
suffering from or affected by any physical infirmity,disease, or illness, irrespective of the injuries?

Yes

No

Yes

No

State whether the patient is confined to bed

Yes

No

Is patient prevented from following his usual businessor occupation as a direct result of his injuries.

Yes

No

If Yes, state for what and when

How was the present accident caused?
After the accident, the first treatment was1) When?
2) Where?

Was patient in your opinion, perfectly sober at thetime of accident?
State as fully as possible the natureand extent of injures sustained :Are injuries on the right or left side?

If Yes, 1) state nature2) extent it impede the recovery of patient
Is patient suffering from or does he suffered from any
cardiac affection, gout, rheumatism, or fits of any kind?
Are you aware of anything in the previous medical
history of the patient which might have contributed
directly or indirectly, to the occurrence of the accident,
or which may be likely in any way to retard hisrecovery from it?

How long in your opinion will patient be so disabled?
State as clearly as possible his present condition

Signature of Physician/Surgeon:

Name & Designation:

Name & address of clinic/hospital:

Date :