Page 1 of 4 Version1.1/Claims/M/June/2015
DEATH CLAIM FORM
Section A
Every question must be fully answered and the Company reserves the right to require further information should it deem necessary. Submission of this Claim Form
does not guarantee admission of liability.
Policy Number
Representative’s Name
Representative’s Code Branch
Representative’s Contact Number
Instructions – Supporting documents required
All Submitted documents have to be Certified True Copy by Etiqa's Representatives or Customer Care Officers
Death Claim Form
Death Statement of Medical Examiner (for policy duration < 5 years)
Certified Copy of Deceased IC or Passport
Certified Copy of Claimant's IC or Passport
Certified Copy of Death Certificate
Certified Copy of Burial Certificate or Cremation Documentation
Original Certificate/Policy Contract
Certified Copy of Proof of Relationship between Claimant and Deceased
Attending Physician Statement
Additional requirements on accidental death
Detailed Post Mortem Report
Certified Copy of Toxicology Report, if any
Certified Copy of Police Investigation Report
Newspaper Cutting, if any
Additional requirements for death in overseas
Confirmation letter from National Registration of Singapore
All relevant documents issued by Foreign Authority must be certified by Singapore Embassy or Public Notary
Method of delivery for claims settlement
Mail Self Collection Collection by Representative Auto Credit
1. Details of Deceased
Name of Deceased
NRIC / Passport Number
Date of Birth
Last Address of Deceased
Marital Status
What family has the Deceased left?
Spouse No of Child Parent
Others, please specify
2. Details of Employer
Name of the Employer of Deceased at the time of death
Address of Employer
Office Telephone Number
Date of Employment (dd/mm/yyyy)
Is the death related to the work?
Yes No
Etiqa Insurance Pte. Ltd. (Company Reg. No. 201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | www.etiqa.com.sg
Page 2 of 4 Version1.1/Claims/M/June/2015
3. Details of Claimant
Name of Claimant
NRIC / Passport Number
Date of Birth
Correspondence Address
Contact Number 1 2
Email Address
What is your relationship with the Deceased?
Is there any Will related to beneficiary?
Yes, please provide true copy of the Last Will, if available No
4. Particulars of Death (due to Illness)
Date of Death (dd/mm/yyyy)
Time (am / pm)
Cause of Death
Place and Country of Death
When did Deceased first complain of or give indication
of his / her last illness? (dd/mm/yyyy)
When did Deceased first consult a Physician for his /
her last illness? (dd/mm/yyyy)
Name & address of doctor Deceased first consulted for
his / her last illness
State the name and address of Deceased's regular
doctor
Please state names and address of every physician who attended to the Deceased during his / her last illness
Date
Consultation
(dd/mm/yyyy)
Date of
Admission
(dd/mm/yyyy)
Date of
Discharge
(dd/mm/yyyy)
Diagnosis Name of doctor & address of hospitals/clinics
5. Particulars of Death (due to Accident or Unnatural Cause)
Date of Accident (dd/mm/yyyy)
Time (am / pm)
Place of Accident
Why was the Deceased at the location?
Describe in detail how the Accident happened?
Was the accident reported to the police?
Yes No (If Yes, please submit a certified copy of police investigation report)
Was the accident reported in the newspaper?
Yes No (If Yes, please submit a copy)
Was an inquest or post-mortem carried out?
Yes No (If Yes, please submit a certified copy of post mortem report)
Page 3 of 4 Version1.1/Claims/M/June/2015
5. Are there other policies in force on the Deceased's life taken with other companies?
Yes No
If Yes, please furnish the following details:
Name of Company Commencement
Date
(dd/mm/yyyy)
Policy Number Type of Coverage Sum Assured
6. Please state your (the Claimant) bank account details in order for us to credit the payment directly into your bank
account.
Bank
Account Number
Identity Card Number (as per bank account)
Claimant's Declaration and Authorisation
I/We hereby declare that I/we are duly authorised to make this claim and all statements and responses whether on this form or otherwise together with any required
questionnaire, amendments, materials and supporting documents submitted in connection with the claim and the Policy (“Information”):
a) declare that all Information is complete, true and correct and that no information or materials have been withheld and that Etiqa Insurance Pte. Ltd. will rely and
act on the Information accordingly. Otherwise, Etiqa Insurance Pte. Ltd. shall be at liberty to deny liability or recover amounts paid, whether wholly or partially;
b) acknowledge and accept that Etiqa Insurance Pte. Ltd. shall be at liberty to deny liability or recover amounts paid, whether wholly or partially, if any of the
Information is incomplete, untrue or incorrect in any respect or if the Policy does not provide cover on which such claim is made; and
c) acknowledge and accept that Etiqa Insurance Pte. Ltd. expressly reserves its rights to require or obtain further information as it deems necessary.
Data Protection and Consent for Use of Information
I/We give consent to Etiqa Insurance Pte. Ltd. to collect, use, disclose and/or process my/our personal data/personal information set out in this form and any other
personal information provided by me/us (collectively the “Personal Information”) and disclose and transfer such Personal Information to any persons and organisations,
whether within or outside Singapore, including but not limited to medical sources, hospitals, doctors, other healthcare professionals, laboratories, regulator, dispute
resolution centres and insurers, their associated persons/organisations, my/our or the insured person’s employers or financial service providers, or their third party
service providers or representatives (collectively “Third Parties”) for the purpose(s) of:
a) processing, handling and/or dealing with my claims including the settlement of the claims and any necessary investigations relating to the claims;
b) carrying out and/or dealing with my instructions or responding to any enquiries by me;
c) administering my claims (including the mailing of correspondence, statements, invoices, reports or notices to me, which could involve disclosure of certain personal
data about me to bring about delivery of the same as well as on the external cover of envelopes/mail packages); and/or
d) complying with applicable law in administering, processing, handling and/or dealing with my claims.
(collectively the “Purposes”)
US Tax Declaration & Acceptance
By ticking the appropriate box, I/We declare my tax status under United States (“US”) tax law. I/We understand that a false statement or misrepresentation of tax
status by a US person (for the purpose of US federal income tax) (“US Person”) leads to penalties under US law.
Non-US Person
I/We represent and warrant that I/we am/are not US Person, and I/we am/are not acting for, or, a US Person. If my/our tax status changes and I/we become a
US Person, I/we agree that I/we shall notify the insurance company(ies) within 30 days from the date of change.
Non-US Person with US Address (or green card holder claiming tax treaty benefits) (Form W8BEN)
US Person (US Tax ID Number: ) (Form W9)
I/We agree to indemnity Etiqa in respect of any false or misleading information regarding my/our US tax status.
US citizens/residents, please sign here
Signature of Claimant
Name :
Contact Number :
Date :
Signature of Witness
Name :
Contact Number :
NRIC / Passport Number :
Relationship to Claimant :
Date :
Page 4 of 4 Version1.1/Claims/M/June/2015
LETTER OF AUTHORISATION / CONSENT
Etiqa Insurance Pte. Ltd. (Company Reg. No. 201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | www.etiqa.com.sg
To obtain further information (Death Claim)
Policy Number
TO WHOM IT MAY CONCERN
I hereby authorise and give my consent to any medical practitioner, physician, surgeon, clinic, hospital, medical centre, insurance company or other organisation,
institution or individual concerned (“the Information Provider(s)’) that may have any records or knowledge of the employment, financial, health or medical history of
(Name of Deceased), (NRIC, Passport Number) and to
provide such information to Etiqa Insurance Pte.Ltd. or its authorised agents and / or employees.
I expressly waive on behalf of myself and / or as a next-of-kin of the Life Assured and for his / her estate all provisions of law or professional ethics forbidding the
Information or (Providers) from disclosing any such information acquired on the Life Assured in a professional and / or client capacity and I further release the
Information Provider(s) and its agent / staff from any liability whatsoever that may arise, in supplying such information requested by the Company.
This authorisation / consent is irrevocable and a copy of it will have the same effect and validity as the original.
Signature / Thumb print of Next-of-Kin / Claimant
Name :
NRIC / Passport Number. :
Relationship with Deceased :
Contact Number :
Date :
