AXA INSURANCE SINGAPORE PTE LTD WORK INJURY COMPENSATION 143 Cecil Street #01-01 GB Building Singapore 069542 CLAIM FORM Tel: (65)6338 7288 Fax: (65)6338 2522 Internet: www.axa.com.sg Co. Reg No. 196900406D All questions must be fully and accurately answered. INSURED 1. Name 2. Business 3. Address 4. Tel. No. 5. Fax No. 6. Email 7. Policy No. 8. Total No. of employees 9. Total earnings for the period of 12 months preceding the accident INJURED 10. Name 11. Sex 12. Age PERSON 13. Address 14. Tel No. 15. H/P No. 16. Nationality 17. NRIC No. / Work Permit No./ Employment Pass No. 18. State occupation in which the injured person is employed 19. Was the injured person engaged in this occupation when the accident occurred? 20. Is the injured person in your direct employment? If not, state name and address of Contractor 21. Name of hospital taken to 22. Inpatient or outpatient medical treatment 23. Has the injured person returned to work? Yes __________________ (when) No __________________ (probable period of disablement) 24. Are you satisfied the injured person has met with a bona fide accident arising out of his employment? 25. Is the injured person able to do partial work? ACCIDENT 26. Date 27. Time 28. Place 29. On what date did you receive notice of accident and from whom? 30. On what date did the injured person actually cease work? 31. Describe exactly how the accident happened 32. If the accident was a result of machinery or gearing work, please state: (a) Whether it was fenced or guarded. (b) Was it being cleaned whilst in motion? 33. What was the general nature of the contract or work going on? 34. State nature of injury 35. State the regions injured 36. Was the injury on the right or left side? 37. Was the injured person under the influence of alcohol or drugs at the time of accident? 38. Was he guilty of any misconduct or disobedience to orders or rules? If so, please give full particulars 39. Who is the negligent party who caused /contributed to the accident? 40. State the names of any persons who witnessed the accident EARNINGS Average Monthly Earnings OF Include - wages overtime bonuses/annual wage supplement allowances (food & quarters) INJURED Exclude - transport allowances employer’s CPF contributions/pensions/monies PERSON money paid to cover any special expenses incurred by the injured person in the nature of employment 41. (a) Commencement date of employment (b) Basic Earnings _________________________________________ $_______ per day $____________ per month (c) No. of working days per week 5 days 5 1/2 days 6 days Others (please specify) (d) Average Monthly Earnings (details of injured person’s earnings for the period of 12 months preceding the accident). Month Gross Monthly Earnings (Excluding Bonus) Annual Wage Supplement/Bonus Paid During Past 12 Months Total Average A1 A2 COMMON To be completed by injured person LAW 42.Do you wish to claim damages against the negligent third party under Common Law? Yes No (Please note that you cannot claim for damages under Common Law if you have made a claim under the Work Injury Compensation Act. To make a claim under Common Law, you must withdraw your claim under the Work Injury Compensation Act in writing to Ministry of Manpower.) Name of Injured Person NRIC Card No./Work Permit No./Employment Pass No. Signature of Injured Person MEDICAL To be completed by injured person CONSENT 43. Medical Information Authority I hereby authorise any hospital surgeon, medical practitioner or clinic or other person who has attended to me or examined me for any reason, to disclose to AXA Insurance Singapore Pte Ltd any and all information with respect to any illness or injury and, to provide to AXA Insurance Singapore Pte Ltd copies of all hospital or medical records, including prior medical history. A photostat copy of this authorisation shall be considered as effective and valid as the original. Name of Injured Person NRIC No./Work Permit No./Employment Pass No. Signature of Injured Person IMPORTANT 1. Please submit the following:- NOTICE (a) Copy of iReport submitted to Ministry of Manpower (MOM). (b) Original claim form (for accidents that do not fall under the Work Injury Compensation Act). (c) Original medical certificates, bills and receipts. (d) Copy of work permit (for foreign employee). (e) Copies of detailed wage payment vouchers of the injured person for the period of 12 months (if injured person has been employed for more than a period of ONE Year) preceding the accident. If the injured person has been employed for less than one year, please forward us the detailed wage payment vouchers from the month of employment up to the date of accident. (f ) Copies of detailed wage payment vouchers during the period of Medical Leave. (g) Copy of the death certificate, if the accident resulted in death of employee. (h) Copies of correspondences exchanged between you and MOM. 2. If there are any details/information that are not readily available, please forward this claim form without delay and supply the missing details/information as soon as possible. 3. According to the Work Injury Compensation Act , each and every accident occurred to your employee/ employees must be reported to MOM through iReport within 10 days of the occurrence of the accident: * Where it results in the death of an employee. * Where it renders an employee unfit for work for more than 3 consecutive days or hospitalized for at least 24 hours. * Where the employee has contracted an occupational disease. Failure to report a work-related accident is an offence which carries a fine of up to S$5,000 for a first-time offence and a fine of up to $10,000 and/or a jail term of up to 6 months for subsequent offences. 4. If the accident is a subject of claim under COMMON LAW, you are to forward to the Company all letters that you have received, or may receive, from the lawyers of the injured person and you must not in any circumstances, admit liability in any manner. 5. The acceptance of this Form is not in itself an admission of liability on the part of the Company. DECLARATION We / I hereby declare that the above information given is true and correct to the best of our/my knowledge and belief. Date Authorised Signature of Insured (with Company Stamp) Designation Name NRIC No. Tel No. H/P No. NRIC No.