1
N
NU
US
S
S
ST
TU
U
DE
D
EN
NT
T
T
TR
R
AV
A
VE
EL
L
I
IN
NS
SU
UR
RA
AN
NC
CE
E
C
CL
LA
AI
IM
M
F
FO
OR
RM
M
©
©
IMPORTANT NOTEThe 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.
P
PO
OL
LI
IC
CY
YH
HO
OL
LD
DE
ER
R
1 Policyholder Policy No.
2 Address
3 Tel/Mobile Email
C
CL
LA
AI
IM
MA
AN
NT
T
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)10
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)
A
C
CL
LA
AI
IM
M
T
TY
YP
PE
E
Please tick box accordinglyFlight 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 8112B
B
D
DE
ET
TA
AI
IL
LS
S
F
FO
OR
R
A
AL
LL
L
C
CL
LA
AI
IM
MS
S
(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 reasonC:\Users\f164223\Desktop\NUS Student Travel Claim Form.doc 3
D.
T
TR
RA
AV
VE
EL
L
D
DE
ET
TA
AI
IL
LS
S
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
E.
T
TR
RA
AV
VE
EL
L
D
DE
EL
LA
AY
Y
/
/
B
BA
AG
GG
GA
AG
GE
E
D
DE
EL
LA
AY
Y
C
CL
LA
AI
IM
M
I
IN
NF
FO
OR
RM
MA
AT
TI
IO
ON
N
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
F.
M
ME
ED
DI
IC
CA
AL
L
/
/
P
PE
ER
RS
SO
ON
NA
AL
L
A
AC
CC
CI
ID
DE
EN
NT
T
C
CL
LA
AI
IM
M
I
IN
NF
FO
OR
RM
MA
AT
TI
IO
ON
N
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:
G
G.
.
C
CL
LA
AI
IM
M
Q
QU
UA
AN
NT
TU
UM
M
F
FO
OR
R
A
A
L
L
L
L
CL
C
LA
AI
IM
MS
S
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
P
P
E
E
R
R
S
S
O
O
N
N
A
A
L
L
D
D
A
A
T
T
A
A
P
P
R
R
O
O
T
T
E
E
C
C
T
T
I
I
O
O
N
N
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
C:\Users\f164223\Desktop\NUS Student Travel Claim Form.doc 5
D
D
E
E
C
C
L
L
A
A
R
R
A
A
T
T
I
I
O
O
N
N
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
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