Work Injury Compensation Claim Form

Work Injury Compensation

Claim Form

Important Information:

The information requested and documents mentioned in this form are a general guide. Further documents or information may be required depending on the circumstances

of your claim. Note that failure to provide supporting documentation may result in delays in the processing of your claim. Your Policy may not provide cover under every

section shown in this Claim Form. The issuance and acceptance of this form does NOT constitute an admission of liability by Chubb Insurance Singapore Limited (Chubb) or

waiver of its rights.

Instructions:

Please download/save this claim form to enter your claim details. Kindly submit the completed claim form via one of the following options:

• By email: WICAclaims.SG@chubb.com (Recommended); or

• Contact your broker/agent.

When submitting your claim, please include copies of the relevant supporting documents. For more information, contact us

• O +65 6398 8000; or

• Visit our website at www.chubb.com/sg

Important Note: Please ensure that you retain the original medical receipts/hospital bills/medical certicates for 3 years. We reserve the rights to request for sight of the

original documents on a need-be basis.

Section A: Particulars of Insured Company and Injured Worker

Name of Insured Company

______________________________________________________________________________________________________________________________________________________________________________________________________________________

Address of Insured Company

Tel No. (Ofce) ____________________________________________________________________ Name of Agent/Broker ____________________________________________________________________

Fax No. (Ofce) ___________________________________________________________________ Total No. of Employees ____________________________________________________________________

Industry of Business ___________________________________________________________________ Email Address ____________________________________________________________________

Policy No. __________________________________________________________________________________________________________________________________________________________________________________

Period of Insurance From DD / MM / YYYY To DD / MM / YYYY

Name of Injured Worker __________________________________________________________________________________________________________________________________________________________________________________

Address of Injured Worker

NRIC/Passport No. ___________________________________________________________________ Nationality ____________________________________________________________________

Date of Birth DD / MM / YYYY Age ____________________________________________________________________

Tel No. (Mobile) ___________________________________________________________________________ Gender

 Male  Female

Tel No. (Residence) ___________________________________________________________________________ Occupation ____________________________________________________________________

Date of Employment DD / MM / YYYY No. of days worked per week ____________________________________________________________________

Direct Employment

 Ye s  No  Others (please specify) ___________________________________________________________

Type of Employment

 Permanent  Contract  Others (please specify) ___________________________________________________________

Was the Injured Worker free from any physical defect or inrmity at the time of accident?

 Yes  No

If No, please furnish with details.

Would such physical defect or inrmity have contributed towards this accident?

 Yes  No

If Yes, please furnish with details.

Section B: Payment Details

Please provide details for payment of your claim in the event that the claim is deemed payable by Chubb.

I hereby authorise and request Chubb to pay benet due in respect of this claim as follows:

 Electronic Funds Transfer (For payments in SGD and to bank accounts in Singapore)

Payee Name (As per bank account name): ______________________________________________________________________________________________________________________________________________________________

Name of Bank: _________________________________________________________________________________________________________________________________________________________________________________________________

Branch Code Number: _______________________________________________________________________________________________________ Account Number: _____________________________________________________

Note: For a more seamless experience, we recommend selecting the Electronic Funds Transfer (EFT) option so you can receive the remittance within 3-5 days upon

approval of claim.

 Cheque Payment (Not recommended)

Payee Name (As per bank account name): ______________________________________________________________________________________________________________________________________________________________

Important Notice:

Chubb shall (i) be discharged from all liability under this claim and (ii) not be liable for any and all losses incurred by you, as a result of you providing Chubb with an

incorrect bank account number under this section for the payment of this claim.

Section C: Details of Accident

Date of the Accident DD / MM / YYYY Time of the Accident (24-hr) H H : M M

Country of Accident __________________________________________________________________ Place of Accident ____________________________________________________________________

Describe in detail how the Accident occurred (Please use supplementary sheet if necessary and also state the type of machinery involved, if any)

When did you receive news of the Accident ______________________________________________________________________________________________________________________________________________________________

When and by whom was the Accident discovered ______________________________________________________________________________________________________________________________________________________

Relationship of person to the Injured Worker ___________________________________________________________________________________________________________________________________________________________

Were there witnesses to the incident?

 Yes  No

If Yes, please provide details below:

Witness 1 Witness 2

Name

Address

NRIC

Contact Number

Describe the nature of the work or contract going on at the material time.

Are you satised that the Injured Worker has met with a bonade accident of employment?

 Yes  No

If No, please state reason(s):

Did this accident occur as a result of another person’s negligence?

 Yes  No

If Yes, please provide details of Negligent party:

Was the Injured Worker guilty of any misconduct/disobedience to orders/rules?

 Yes  No

If Yes, please state the misconduct:

Was the Injured Worker under the inuence of drink or drugs at the material time?  Yes  No

If Yes, please specify:

Has the Injured Worker met with any previous accident under your employment?

 Yes  No

If Yes, please furnish details:

Has this accident been reported to the Ministry of Manpower?

 Yes  No

If Yes, please attach a copy of I-REPORT.

Please state the date that the Injured Worker returned to work DD / MM / YYYY

Section D: Nature of Injury

Describe in detail the injuries sustained, indicating the Part(s) of body injured and its type of injury (E.g. Fracture, Cut, Bruise, etc).

(Please use supplementary sheet if necessary)

Has the Injured Worker ever had this or any similar condition or injury?

 Yes  No

If Yes, please furnish details:

Please state all medical condition(s) or previous injury sustained by the worker and also indicate which are the injuries that arose out of Work Injury accidents.

(Please use supplementary sheet if necessary)

Date of rst treatment sought DD / MM / YYYY

Name of Hospital/Clinic _______________________________________________________________________________________________________________________________________________________________________

Address of Hospital/Clinic _______________________________________________________________________________________________________________________________________________________________________

Tel/Fax No. _______________________________________________________________________________________________________________________________________________________________________

Period of Hospitalisation From DD / MM / YYYY To DD / MM / YYYY

Period of Medical Leave From DD / MM / YYYY To DD / MM / YYYY

Light Duties From DD / MM / YYYY To DD / MM / YYYY

Work Injury Compensation Claim Form. Singapore. Published 09/2020.

are protected trademarks of Chubb. 4

Section E: Detailed Earnings of The Injured Worker

Please provide detailed gross monthly earnings of the Injured Worker for 12 months (before month of accident):

Month/Year Gross Monthly Earnings

(Exclude Bonuses, Transport Allowance, CPF Employer’s Portion)

Annual Wage Supplement/Bonus Paid During Last 12 Months

Total Annual Earnings

Average Monthly Earnings

Section F: Declaration

Did you remember to enclose the following? (Where applicable)

Document Yes N/A

Copy of iReport submitted to Ministry of Manpower

 

Medical Bills and Medical Certicates

 

Copy of Salary Vouchers for the last 12 months (before month of accident)

 

Copy of Work Permit or Employment Pass (for Foreign employees)

 

Written notes from Physician on type of injury sustained/Inpatient Discharge Summary or Medical Report

 

Copy of Death Certicate, Post Mortem Report, Autopsy Report, Police Reports, Letter of Administration (if involved fatalities)

 

Copy of Contractual Agreement between Insured, Sub-Contractor(s) and/or Main Contractor

 

Copy of Sub-Contractor’s and/or Main Contractor’s Work Injury Compensation Insurance Policy

 

By signing this form, I/We agree that Chubb will use the information supplied here and during the formation and performance of the policy, for policy administration, customer

services, claims handling and fraud analysis and prevention, and that Chubb may disclose such information to its service providers, agents, authorities and other parties for these

purposes.

I/We hereby authorise any hospital, physician, and any other person or entity who has attended to or examined the injured party, to furnish to Chubb or its authorised

representatives, any and all information with respect to any illness or injury or loss, medical history, consultation, prescriptions or treatment, copies of all hospital, medical or other

records, investigation status and results, and such personal information as Chubb in its absolute discretion considers relevant for its assessment of this claim. A photostatic copy of

this authorisation shall be considered as effective and valid as the original.

I/We do solemnly and sincerely declare that the foregoing particulars are true and correct in every detail and I/We agree that if I/We have made or in any further declaration or

representation shall make any false or fraudulent statements or suppress, conceal or falsely state any fact whatsoever the Policy shall be void and all rights to recover thereunder in

respect of past, present or future claims shall be forfeited.

_____________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________

Name and Designation of Authorised Person Signature with Company Stamp Date (DD/MM/YYYY)

_____________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________

Name of Injured Worker Signature of Injured Worker Date (DD/MM/YYYY)

______________________________________________________________________

NRIC/Passport No./Work Permit No. of Injured Worker

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