AXA INSURANCE PTE LTD

redefining insurance 8 Shenton Way #24-01 AXA Tower

Singapore 068811
Customer Care Team #B1-01
Travel Claim Form 1800 880 4888
cst@axa.com.sg
Policy/ Certificate No.
www.axa.com.sg
Co. Reg No. 199903512M

To expedite your claim, please (1) Complete this form, (2) Prepare the relevant documents listed on page three and four,
and (3) Mail them to AXA Office within 30days from the date of return to Singapore. Thank you.

A. POLICY INFORMATION

Policyholder’s Full Name

B. CLAIMANT DETAILS

Full Name NRIC/FIN No.

Email Mobile No.

Correspondence Address

C. TRAVEL & LOSS DETAILS

Travel Period (DD MM YY) From: Travel Agency (if applicable)

To:

Date and Time of Loss/ Accident Location of Loss/ Accident

Date:

Time:

Type of Loss/ Accident

Death/ Total Permanent Disablement

Medical & Dental Expenses
Loss/ Damage of Personal Effects
Baggage or Travel Delay
Trip Curtailment
Flight misconnection
Others ( )

Description: Circumstances of the Loss/ Accident or Nature of Illness

*If space is insufficient, please give details in a separate paper.
Total amount claimed (SGD)

Have you made a claim against any other party in respect of this event? If yes, please provide

Name of other party / insurance company:

Description of claim:

D. BANK ACCOUNT DETAILS

Please provide your bank details for us to accelerate your claims payment process by direct transfer to your bank account.

Name (as per bank account)

Bank Name Bank Code

Account No. Branch Code

E. DECLARATION, AUTHORIZATION & CUSTOMER’S DATA PRIVACY CONSENT

[Declaration] I/We confirm that I am/We are the claimant and/or the Policyholder and I/We declare that all the particulars
given above are to the best of my/our knowledge true and correct.

[Authorization] I / We hereby consent to and authorize the medical practitioner involved in the claimant’s care to discuss
and disclose treatment details and discharge arrangements with and to AXA Insurance Pte Ltd. I/We agree that a copy
of this consent shall have the validity of the original.

[Customer’s Data Privacy Consent] In connection with my/our and/or the claimant’s claims, I/We give consent for
AXA Insurance Pte Ltd (“AXA”) and their respective representatives or agents to collect, use, store, transfer and/or
disclose the information (including that provided by sources other than myself) concerning me/us and/or the
claimant, to or with all such persons (including any member of the AXA Group or any third party service provider, and
whether within or outside of Singapore and the Policyholder when claiming under a Group Policy) for the purpose of
enabling AXA and their respective representatives or agents to provide me/us and/or the claimant (where applicable) with
services required of an insurance provider, including the evaluating, processing, administering and/or managing my/our
and/or the claimant’s claims or the Policyholder Group Policy(ies) with AXA (as the case may be), and for the purposes
set out in AXA’s Data Use Statement which can be found at http://www.axa.com.sg (“Purposes”).

Date: _______________________ Date: ____________________________

____________________________ _____________________________________________________
Signature of Claimant Signature of Policyholder - For minor and group policy
(Please also provide Company Stamp for corporate policy)

TRACK YOUR CLAIM STATUS

Once your claim is registered, you will be updated through e-mail. Should you have any query on your claim status, we would
be pleased to assist you via the following:

www.axa.com.sg
(Claim Section) 1800 880 4888 cst@axa.com.sg

AXA Insurance is committed to making your claim submission simple and easy.
Thank you for insuring with AXA Insurance, we are proud to serve you.
DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT

Below is a list of minimum documentation required to process your claim. In certain circumstances, additional
information may be required in order for further confirmation. Please note coverage is subject to type of policy purchased

Type of Loss/ Damage Documents Required (Please tick against the documents you have submitted)

Completed travel claim form

Basic for all types Proof of travel (e.g. boarding pass or Air tickets)
Copy of Certificate of Insurance (For group policies)
(plus) as applicable below:
Medical report from the attending doctor abroad
Accidental Death, Death Certificate - if applicable
Total Permanent Post Mortem Report - if applicable
Disablement Police Report - if applicable
Investigation report - if applicable

Medical expenses, All original medical invoices and receipts

Hospitalisation Allowance, Medical report from the attending doctor abroad
Hospital Visit benefit, Admission/Discharge Report - for Hospitalisation claims only
Compassionate Visit, Child Receipts for additional expenses claimed for additional travel & accommodation - for
Care Benefit Hospitalisation claims only
Regular Medical Practitioner report - for Hospitalisation claims only
Purchase receipts and/or warranty cards
Documents stating amount of compensation from airlines or other sources (if applicable)
Loss/ Damage to Property Irregularity Report for losses in carriers’ custody (if applicable)
Baggage & Photographs to show extent of damage and original repair invoices (for Damage Claims)
Personal Effect Police report / loss report lodged at the place of loss within 24hours (for Theft Claims
only)
List of items stolen with the information on make/model, date purchase and purchase
price (Theft claims only)
Purchase of Police report / loss report lodged at the place of loss (within 24hours)
Essential Items Receipts of the essential items purchased

A copy of flight itinerary indicating the original flight details

Baggage Delay Written confirmation / acknowledgment receipt from the airline on the date and time of
baggage received

Personal Money Police report lodged at place of incident within 24 hours and detailing the
& Travel Documents circumstances and list of items stolen
Receipts for additional costs incurred in replacing lost travel document
A copy of flight itinerary indicating the original flight details
Booking invoice with terms and conditions, and payment receipts
Trip Cancellation/ Medical Report / Death Certificate (if applicable)
Travel Curtailment Proof of relationship (if applicable)
Written confirmation of the refund amount from the travel agents / airline
Invoice & receipt for charges incurred in amending or purchasing additional air ticket
(for trip curtailment, if applicable)
A copy of flight itinerary indicating the original flight details
Trip Postponement/ Confirmation from airlines / travel agents with regards to the change of flight details
Replacement of Receipts of the administrative charges (if applicable)
Traveller Death Certificate, Medical Report (if applicable)
Proof of relationship (if applicable)

Travel Delay/ A copy of flight itinerary indicating the original flight details
Travel Diversion A written confirmation or Report from Airline on duration of diversion or delay and
reason

Travel Overbooked or A copy of flight itinerary indicating the original flight details
Misconnected A written confirmation from Airline confirming the overbooked or misconnected flight
details and when the next alternative transportation is made available
 Police Report (to be lodged within 24hours)
Fraudulent Use of Loss report by credit card company (to be lodged within 6hours)
Lost Credit Card Statement issued by the issuing bank showing the record of unauthorized use of
credit card including date and time of notification of loss
Personal Liability Forward all correspondence & documents from third parties to us for our
handling

Financial Collapse of
Receipts of the irrecoverable travel deposits or travel fares paid in advance
Travel Agency

Copy of Car Rental Agreement & payment receipt of the rental charge
Copies of the driver's driving license at the time of accident
Rental Car Excess
Copy of overseas motor insurance policy (if available)
Cover
Receipts of the excess paid
Copy of Police Report (if applicable)
Emergency Personal Mobile phone bill indicating the actual telephone charges incurred for the use of
Mobile Phone Your personal mobile phone whilst overseas during a medical emergency to
Charges engage the services of AXA Assistance Singapore
Loss of Sports Receipt for the Loss / Damage Equipment
Equipment, Golf Receipt of the replace/repair receipt for the damage Equipment
Equipment, Loss report / police report made within 24hours (if applicable)
Hole-in-one “Hole in One” certificate from the Golf Club Professional & drinks receipts to
Celebration celebrate Hole-in-One
Written confirmation from Public Transport stating the reason of delay and the
details of the actual departure time
Pet Care Written confirmation from the kennel/cattery or pet hotel stating the original and
actual pick-up dates
Quarantined Written confirmation from the relevant health authority on the nature and period of
Allowance for the quarantine
Influenza A Medical report from the attending doctor abroad / health officer
Hijacking A written confirmation from Airline confirming the incident and duration
Inconvenience

Kidnap & Hostage Police Report

Photographs of damaged items
Receipts for all items claimed. If not available, provide description of items and
Home Care Benefit
the date, place and price of purchase
SCDF Report (if applicable)
A copy of the death certificate of the family member (if applicable)
Proof of relationship for Death of Family member (if applicable)
Study Interruption
A copy of your hospitalization bill
Regular Medical Practitioner report – for Hospitalisation claims only
Admission/Discharge Report – For Hospitalisation claims only
Proof of tuition fees payment to the educational institution