EQ FWMI Form

STEP 1 – POLICY & CLAIM DETAILS

IMPORTANT NOTE

1.	The policyholder and/or the insured person(s) must truthfully give information and particulars to the best knowledge and belief.
2.	We are not admitting to any legal responsibility by accepting this claim form.
3.	If the claim is found to be fraudulent, or if any fraudulent means or devices are used to obtain any policy benefits, the policy will be rendered void.
4.	Notify or submit your claims to EQI as soon as possible as late claims notification may be a breach of policy condition. (please refer to policy wordings)

Policy Number

Employer’s Details

(To Be Completed By The Employer & All Fields Are Mandatory)

Name of Policyholder

Name of Authorised Representative

Email 1

Email 2

Email 3

Contact No.

STEP 1 – POLICY & CLAIM DETAILS

Employee’s Details

Name of Employee

FIN No

Date of Birth

Gender

Male

Female

Date of Employment

Job Designation

Plan No. (if applicable)

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STEP 1 – POLICY & CLAIM DETAILS

Details Of Injury / Illness

Due to accident

Date of Accident

Time of Accident

Place of accident

Is this a work-related injury?

Yes

How did the accident occur

Nature of injuries sustained

For road traffic accident claim, please confirm whether the accident involving third party?

Yes

If yes, please state

(i) Vehicle No. of third party

(ii) Motor Insurer of third party

Due to illness

Date symptoms first commenced

Diagnosis / description of symptoms

Date of admission / surgery

Type of operation / surgical procedure

Have you claimed or do you intend to claim from any other insurer for this illness / injury?

Yes

If yes, please state all the claims submitted

(i) Name of Insurer(s)

(ii) Details of law firm engaged (if any)

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STEP 2 – UPLOAD DOCUMENTS

UPLOAD DOCUMENTSⓘ

Please provide: a) Medical bills, work permit and medical memo / medical report from the attending doctor stating the nature of injury if insured person is treated as an outpatient as a result of an accident.
b) Hospital final bill, medical certificates, work permit, wages and levy statement, inpatient discharge summary / medical report if insured person is hospitalized as a result of an accident / illness.

EQ Insurance will accept electronic copies of final medical bills / tax invoices / receipts. However, we reserve all rights to request for the original documents within 12 months from the date of submission. In the event that the original final medical bills / tax invoices / receipts are not available during our review, EQ Insurance reserves the right to recover any claims that have been paid by EQ Insurance to the Policyholder / Insured Person.

Total Size : 0 MB
(Please note: Total file size should be less than 20MB)

INVOICES

Delete

OTHERS

Delete

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STEP 3 – PAYMENT

NOTE EQ INSURANCE COMPANY LIMITED shall not be liable for any losses incurred by you as a result of providing inaccurate PayNow registered details or bank account details.
(Letter of Authorisation is required if payee for PayNow Linked Account or Bank Transfer is not the insured)

Payment Method

PayNow Linked Account

Bank Transfer

Cheque payee name:

(Note: An administrative fee based on the issuing bank's prevailing charges will be imposed for every lost/re-issued cheque)

Note: please state NA if not applicable for NRIC/FIN or mobile no. or UEN

PayNow registered name

PayNow registered NRIC/FIN or mobile number

PayNow registered UEN (for corporate account)

Bank name

Bank account holder's name

Bank account number

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STEP 4 – REVIEW

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STEP 5 – DECLARATION & AUTHORISATION

DECLARATION, AUTHORISATION AND DATA PRIVACY CONSENT BY INSURED

By submitting this claim, I/we declare, authorise, and consent to the following:

1.Accuracy of Information
All statements, answers, and documents provided are complete, accurate, true, and not misleading to the best of my/our knowledge and belief. I/We will promptly inform EQ Insurance Company Limited ("EQI") of any changes affecting this claim.

2.Consequences of Fraud or Misrepresentation
Any false, fraudulent, or misleading statement, or concealment of material facts, may result in rejection of this claim, forfeiture of policy rights, voidance of the policy, recovery of paid amounts and costs, and reporting to the Singapore Police Force, GIA Fraud Register, and other relevant authorities.

3.Authorisation (Third-Party / Corporate Policies)
In cases where I/we are not the policyholder, or in the scenario of a corporate policy, I/we confirm that I/we have been duly authorised by the insured member(s) (hereafter referred to as the ‘Insured’) to provide relevant information pertaining to the claims. I/we acknowledge full responsibility for ensuring the accuracy and validity of this submission. Furthermore, I/we agree to indemnify EQI against any losses or claims arising from this submission.

4.Medical & Records Authorisation
I/We authorise EQI and its representatives to obtain and disclose any relevant information from hospitals, doctors, employers, individuals, organisations, or authorities relating to illnesses, injuries, medical history, consultations, treatments, diagnostic tests, hospital admissions (past, present, or pending/recommended), and employment/wage records. This authorisation remains valid throughout the claim, appeal, and recovery process. A photocopy, scanned, or electronic copy of this authorisation is as valid as the original.

5.Personal Data Protection (PDPA)
I/We consent to EQI's collection, use, disclosure, processing, and retention of personal data for claim, policy, fraud prevention, recovery, and regulatory purposes. Data may be shared with EQI's authorised representatives, intermediaries, service providers, reinsurers, legal/regulatory bodies, industry databases, and dispute resolution forums, in line with EQI's Personal Data Protection Statement available at www.eqinsurance.com.sg.

6.Anti-Fraud, AML & Sanctions
I/We declare this claim is not connected to any sanctioned party or unlawful activity and consent to sanctions, AML, and fraud screening checks in line with MAS requirements.

7.Other Insurance & Subrogation
I/We have disclosed all other insurance policies covering the same loss/event and agree to fully cooperate with EQI in any recovery or subrogation action, without prejudicing EQI's rights.

8.Authenticity of Documents
All documents submitted are genuine, unaltered, and true copies.

9.Electronic Submission
I/We agree that submission via the online tick-box constitutes a legally binding signature under the Electronic Transactions Act 2010 of Singapore.

I/We have read, understood, and agree to the above declarations, authorisations, and consents.

Date

Verification Code

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THIS SECTION MUST BE COMPLETED

FOREIGN WORKERMEDICAL INSURANCECLAIM

FOREIGN WORKER
MEDICAL INSURANCE
CLAIM