AXA INSURANCE SINGAPORE PTE LTD Cecil Street GB Building Singapore

							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.