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FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies

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IMPORTANT NOTE

The Insured is requested to state as fully and as accurately as possible the information asked for hereunder in order to expedite claim processing. Please ensure that all relevant supporting documentation is submitted within 30 days from date of return with this claim form. If any information or documents are currently not available, please let us know and state the reason(s). Any documentary proof or reports required by the Company shall be furnished at the expense of the Policyholder or Claimant. Thank you for your assistance to enable us to expedite claim processing. Our acceptance of this Form is not in itself an admission of liability on the part of the Company.

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1 Policyholder Policy No.

2 Address

3 Tel/Mobile Email

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Marital Status Married Single

4 Student Sex F M Age

5 Home Address

Nationality & NRIC/Passport No.

6 Email Tel/Mobile

7 Insured Person’s prior medical insurer, if insured less than 12 months under this policy

8 Are there any other insurance which would cover this loss? Yes No

9 Name of Insurance Company & Policy No. _____________________________________________________________________

If Yes, please submit claim to the other insurance company and provide copies of policy and completed claim form for our review.

INFORMATION FOR PERSONAL DEVIATION (PD)

Cumulatively up to maximum of 31 days (Questions 10 to 13 only)

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Commencement Date of Official NUS Student Trip

11 City / Country of Official NUS Student Trip 12 Home / Country of Residence

13 Total No. of days taken before current trip (PD)

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Please tick box accordingly

Flight Delay Medical Expenses Trip Cancellation Loss / Damage to Personal Effects Baggage Delay Missed Connection Trip Curtailment Loss of Money / Documents

Baggage Loss Personal Insurance Personal Liability Permanent Disablement / Accidental Death

Others

FEDERAL INSURANCE COMPANY

One of the Chubb Group of Insurance Companies

18 Cross Street #11-08 China Square Central Singapore 048423 Telephone: 6333 8113 Facsimile: 6333 8112

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(Please attach a separate sheet if space below is insufficient)

Date and Time Place

NOTE: If you are claiming for MEDICAL EXPENSES incurred, the

doctor’s diagnosis and/or the cause or reason

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C:\Users\f164223\Desktop\NUS Student Travel Claim Form.doc 3

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PLEASE COMPLETE THIS SECTION FOR CLAIM INVOLVING TRAVEL OVERSEAS

Duration of Trip From To

You can omit the following if a copy of your travel itinerary or e-ticket is submitted with this claim form

1. Departure Airport Carrier / Flight No. Date and Time 2. Transit Airport, if any Carrier / Flight No. Date and Time 3. Arrival Airport Carrier / Flight No. Date and Time

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1. FLIGHT DELAY Airport Delayed Flight No. Date & Time

2. MISSED CONNECTION Airport Delayed Flight No. Date & Time

3. BAGGAGE DELAY / LOSS Airport Place of Receipt Date & Time

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Have you ever suffered this or a similar condition or was this recurrence of a previous illness or injury? If yes, please provide details, including dates

Yes No Dates and Details

Names and addresses of usual attending Physician(s):

For Accident, names and addresses of witnesses, if any:

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PLEASE STATE BRAND / MODEL NO. FOR LOST PROPERTY OR BAGGAGE CLAIMS TO AID CLAIM ASSESSMENT

Purchase Date or

Consultation Date Description of Lost/Damaged Items or Medical Services /Treatment

Original Price Paid or Consultation Fees

Replacement or

Repair Costs Claimed Amount

Please attach a separate list if space is insufficient above

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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)

processing, handling and/or dealing with my claims including the settlement of the claims and any necessary

investigations relating to the claims;

(ii)

investigating the accident and/or my claims;

(iii)

carrying out and/or dealing with my instructions or responding to any enquiries by us/me;

(iv)

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

(v)

complying with applicable law in administering, processing, handling and/or dealing with us/my claims.

(collectively the “Purposes”)

(b)

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

(c)

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

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We/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.

We/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.

We/I also hereby authorise any hospital, physician, or other person who had examined me or attended to me, to disclose when requested to do so

by Federal Insurance Company or its authorised representative, any and all information with respect to any illness, or injury, medical history,

consultations, prescriptions or treatment, or incident or copies of all hospital or medical records or any records. A photocopy of this authorisation

shall be considered as effective and valid as the original.

PAYMENT OF CLAIM

Subject to Policy terms and conditions, I/we hereby authorise and request Federal Insurance Company to pay the benefit due in respect of

this claim to:

.

Note: Payment is made in the form of Singapore Dollars cheque, regardless of the Insured Person/Claimant’s Home Country or Country of Residence/Secondment or the nationality or location of the Policyholder.

Name & Signature of

Insured Person and/or Claimant Date

Name, Signature & Designation of Policyholder’s Representative / HR Personnel & endorsed with

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FEDERAL INSURANCE COMPANY

OVERSEAS / BUSINESS TRAVEL INSURANCE CLAIM SUPPORTING DOCUMENTS

The list of supporting documentation stated below is not exhaustive and we reserve our right to

request any additional information/documentation, as necessary. The submission of an

incomplete form or insufficient information or supporting documents may delay the processing

or result in the denial of your claim.

To facilitate consideration of your claim, please ensure you submit the essential supporting

documents together with the completed claim form as soon as possible. We will contact you if

additional documents or information are necessary.

Please tick documents attached:

For all Travel Claims submitted

Completed claim form (Note: Claim Form must be endorsed with company’s stamp and signed by an authorised NUS’s representative including a copy of approval document for the Official Student Trip)

Original air tickets and boarding passes for the entire trip Copy of travel itinerary for the entire trip

Flight Delay or Missed Connection

Airline written confirmation stating reason(s) for delay and the length of delay Airline’s letter or any documents confirming date and time of re-scheduled flight

Original invoices/receipt(s) for additional expenses for accommodation and travel (if applicable) Airline’s letter stating compensation (if applicable)

Baggage Delay

Airline baggage tag

Airline Property Irregularity Report stating date / time of delay Documents confirming date / time baggage was returned Airline’s letter stating compensation (if applicable) Loss of Money,

Passport or Documents

Original copy of police report

Original invoices / receipts for expenses incurred to replace lost documents Documents to substantiate claim quantum

Loss of or Damage to Baggage or Personal Effects

Original copy of police report

Original property irregularity report from airline, airport authority or hotel confirming loss or damage Original airlines’ letter stating compensation for lost / damaged items

Original invoice/receipt of damaged or lost items Photo of damaged item and repair quotation (if any)

Repair invoice/receipt of damaged item with details of damage sustained and repair work done If item is replaced, copy of invoice / receipt of replacement item

Trip Cancellation or Trip Curtailment

Certified true copy of death certificate and documents (e.g. birth certificate, marriage certificate) to prove relationship between Insured Person/Claimant and deceased

Medical report and/or other documents to substantiate the reason for trip cancellation or trip curtailment Original invoices/receipts showing any pre-paid costs or deposits made and not refunded

Original documentation/receipts indicating the additional travel and/or accommodation expenses incurred Medical Expenses Original medical bills/receipts Original medical report or certification from the attending Physician stating diagnosis or reason for treatment

Permanent Disablement / Accidental Death

Original copy of police report and newspaper report, if available Original medical report

Additional documents for Accidental Death Claim:

Certified true copy of death certificate, coroner’s report or autopsy report (if any)

Certified true copy of claimant’s identification documents (such as identity card, passport, marriage or birth certificate) to prove relationship between Claimant and Insured Person

References

Related documents

Flight Delay Medical Expenses Trip Cancellation Loss / Damage to Personal Effects Baggage Delay Missed Connection Trip Curtailment Loss of Money / Documents Baggage Loss

This Travel Package policy provides cover for medical expenses, repatriation, trip cancellation, personal accident and loss or damage to personal baggage.. What is insured under

a) The delay of Your or Your Travelling Companion’s prepaid Common Carrier that is part of Your Trip due to weather conditions, earthquakes or volcanic eruptions for a period of

 Trip Cancellation/ Trip Interruption and Trip Delay  Emergency Medical and Dental Expenses  Emergency Medical Transportation  Baggage Coverage.. 

Trip Cancellation Insurance and the Trip Interruption and Delay benefit do not cover losses or expenses incurred for or as a result of a Pre-existing Condition which required

Plans Eligible Age* Trip Cancellation & Interruption** Emergency Medical Baggage Loss, Damage & Delay Flight Accident Travel Accident Rental Vehicle Damage Insurance

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In the case of Trip Interruption benefits, Flight & Travel Accident, Baggage Loss, Damage & Delay and Rental Vehicle Damage Insurances, it means the place you leave from