Liability

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.

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Section A: Particulars of Policyholder / Insured Person

Name of Policyholder / Insured Person (as shown in NRIC / Passport)

___________________________________________________________________________________________________________________________________________________________________________________________

Address of Policyholder / Insured Person

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________ Postal Code ______________________________

Policy No. ___________________________________________________________________________________________________________________________________________________________

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

Tel No. (Mobile) _________________________________________________________ NRIC / Passport No. _______________________________________________________________

Tel No. (Residence) _________________________________________________________ Age _______________________________________________________________

Tel No. (Office) _________________________________________________________ Nationality _______________________________________________________________

Date of Birth DD / MM / YYYY Gender ☐Male ☐Female

Date of Employment DD / MM / YYYY Occupation _______________________________________________________________

Email ___________________________________________________________________________________________________________________________________________________________

Name of Intermediary (if any) ____________________________________________________________________________________________________________________________________________________

Name of Insured Person (if different from Policyholder)

___________________________________________________________________________________________________________________________________________________________________________________________

Address of Insured Person

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________ Postal Code ______________________________

Tel No. (Mobile) _________________________________________________________ NRIC / Passport No. _______________________________________________________________

Tel No. (Residence) _________________________________________________________ Age _______________________________________________________________

Tel No. (Office) _________________________________________________________ Nationality _______________________________________________________________

Date of Birth DD / MM / YYYY Gender ☐Male ☐Female

Date of Employment DD / MM / YYYY Relationship to Policyholder _____________________________________________________

Occupation ___________________________________________________________________________________________________________________________________________________________

Email ___________________________________________________________________________________________________________________________________________________________

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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 benefit due in respect of this claim as follows:

☐ Cheque Payment

Payee Name (as per bank account name) _________________________________________________________________________________________________________________________________

☐ 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 No. ______________________________________________________________ Account No. _____________________________________________________________________________

If no name is provided, settlement will be effected to the payee as provided for under the terms of the policy.

Section C: Details of Loss / Occurrence

Country of Loss / Occurrence ☐Singapore ☐Malaysia ☐Others ___________________________________________________________________

Place of Loss / Occurrence _______________________________________________________________________________________________________________________________________

Date of Loss / Occurrence DD / MM / YYYY Time of Loss / Occurrence (24-Hour) HH:MM

Describe how the incident / loss took place (Please use supplementary sheet if necessary)

____________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________

When and by whom was the loss discovered ___________________________________________________________________________________________________________________________________

Relationship of Third Party Claimant to the Insured __________________________________________________________________________________________________________________________

Were there witnesses to the incident? ☐Yes ☐No

If Yes, please provide details below:

Witness 1 Witness 2
Name
Address

NRIC

Contact Number

Section D: Police Report

Please note:
1) The Police must be informed immediately if the property has been lost or maliciously damaged.
2) A copy of the Police Report / Statement must be attached.

Were particulars of loss taken by or reported to the Police? ☐Yes ☐No

If Yes, please furnish with details below:

Name of Police Station ______________________________________________________________________________________________________________________________________________________________

Date of Report DD / MM / YYYY Time of Report (24-Hour) HH:MM

Page 3 of 6
If No, please state reason(s) that the Loss was not reported to the Police:

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Section E: In Product Cases Only

Please give details of the product alleged to have caused injury / damage; your opinion on cause; details of any defects; identity of distributor /
retailer and other comments. (Please use supplementary sheet if necessary)

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

What duty did you owe to the Third Party Claimant, Injured person or Owner of damaged property?

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

How could you have prevented the incident?

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Section F: Details Of Person(s) Injured

(Please use supplementary sheet if necessary)

Name, Address and Contact No. of Age Nature of Injuries / Name of Hospital The Occupation / Nature of
Person Injured Remarks Person Injured was Work
Conveyed To

Is he / she in your employment? ☐Yes ☐No

Was he / she under the influence of intoxicating liquor or drugs at the time of accident? ☐Yes ☐No
If Yes, please give details:

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Was he / she guilty of misconduct, or of disobedience to instructions or rules? ☐Yes ☐No

If Yes, please state the nature:

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

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In your opinion, was he / she responsible for the incident? ☐Yes ☐No
If Yes, please state the reason(s):

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Section G: Details of Property Damaged

(Please use supplementary sheet if necessary)

Name, Address and Contact No. of Owner Name and Extent of Property Approximate Value Estimated Cost of
of Property Damaged Damaged of Property Repairs to The
Damaged Property Damaged

Has any claim been made upon you? ☐Yes ☐No

If Yes, please state details and attach all communications received from third party claimant(s):

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Have you admitted responsibility in any way? ☐Yes ☐No

If Yes, please state the reason(s) for doing so:

___________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

Section H: Any Other Insurance

Are there any other policies of insurance in force covering you or the subject matter in respect of this event? ☐Yes ☐No
If Yes, please specify below:

Name and Address of Insurance Company(s) Policy No(s).

Are you claiming under any of the policies listed above? ☐Yes ☐No

Page 5 of 6
Section I: Claims History

Have you or any Insured person previously made claim(s) for loss / damage or caused damage / injury to third parties? ☐Yes ☐No
If Yes, please furnish with details below:

(Please use supplementary sheet if necessary)

Name of Insurer Claim No. Date of Loss Nature of Loss Amount Paid

Section J: Declaration

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

Document Yes NA

Incident or Investigation Report ☐ ☐

Police Report ☐ ☐
CCTV footage (i.e. Evidence of circumstances leading to the incident) ☐ ☐
Photographs showing the damage to the items and / or bodily injuries ☐ ☐
Copy of Assessment Report / estimates from Repairer indicating the cause and extent of damage incurred
(if involved damaged item(s))
☐ ☐
Copy of Medical Report of third party/parties (if involved bodily injuries) ☐ ☐
Settlement / Contractual Agreement from third party / parties concerned (if involved bodily injuries) ☐ ☐
Letter of Demand from the third party / parties concerned (e.g. Writ of Summons) ☐ ☐

By signing this form, I / We agree that Chubb Note:

will use the information supplied here and
during the formation and performance of _______________________________________________________
Kindly submit the completed claim form in
the policy, for policy administration, Name and Designation of Policyholder
person, through your Broker, or by mail to
customer services, claims handling and
Chubb Insurance Singapore Limited at 138
fraud analysis and prevention, and that
Market Street #11-01 CapitaGreen Singapore
Chubb may disclose such information to its
048946. Please ensure that the relevant
service providers, agents, authorities and
original copies of supporting documents are
other parties for these purposes. _______________________________________________________
submitted as well.
Signature with Company Stamp
I / We authorise any person or entity to (if applicable)
provide to Chubb or its authorised
representatives, any and all information _______________________________________________________ Contact Us
with respect to any loss and claims, police Date
records, investigation status and results, and Chubb Insurance Singapore Limited
such personal information as Chubb in its Co Regn. No.: 199702449H
absolute discretion considers relevant for its 138 Market Street
assessment of this claim. A photostatic copy _______________________________________________________ #11-01 CapitaGreen
of this authorisation shall be considered as Name of Insured Person Singapore 048946
effective and valid as the original. (if different from Policyholder) O +65 6398 8000
F +65 6298 1055
I / We do solemnly and sincerely declare www.chubb.com/sg
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 Signature of Insured Person
any false or fraudulent statements or
suppress, conceal or falsely state any fact _______________________________________________________
whatsoever the Policy shall be void and all Date
rights to recover thereunder in respect of
past, present or future claims shall be
forfeited.

© 2016 Chubb. Coverages underwritten by one or more subsidiary companies. Not all coverages available in all jurisdictions. Chubb® and its
respective logos, and Chubb. Insured.SM are registered trademarks.
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Published 04/2016.