Commercial Fidelity Guarantee Claim Form

AXA INSURANCE PTE LTD
redefining insurance 8 Shenton Way #24-01 AXA Tower

Singapore 068811
Customer Care Team #B1-01
FIDELITY GUARANTEE CLAIM FORM 1800 880 4888
cst@axa.com.sg
Policy/ Certificate No.
www.axa.com.sg
Co. Reg No. 199903512M
The issuance of this form is not an admission of liability. It should be completed as fully and accurately as possible and
returned immediately.
A. POLICY INFORMATION
Policyholder’s Full Name
B. CLAIMANT DETAILS
Full Name (if different from policy holder)
Email Telephone No.
Is your company GST Registered? Yes No
C. LOSS DETAILS
Name of the Employee
Address of the Employee
Mobile No. of the Employee
Date of Employment Occupation
Remuneration Date of Termination
Has the employee been continuously in your service since the date of employment?
Yes No please provide details.
When was it discovered and by whom?
Date the Employee first committed the act of fraud or dishonesty. If there were more than one occasion, state the respective
dates of such acts of fraud or dishonesty.
By what method and in what circumstances were the acts of the fraud or dishonesty committed?
What were the Loss and Value?
Does the employee agree with the amount of the deficiency? Yes No Was
there any checks and supervision in place?
No Yes please provide name of supervisor

Was there any previous similar incident committed by the Employee?
No Yes please provide details.
Is there any other insurance covering the same loss?
Any money or property in your custody due or belongings to the employee?

Please note that any such money or property should be retained by you pending our instructions.
No Yes please specify amount.
Do you know the present whereabouts of the employee?
No Yes please give precise details
Are you in communication with the employee or with any member of his/her family?
Have you removed from the employee’s custody all goods or other property belonging to you?
Yes No please provide details.
Have this employee’s customers (if any) been advised that he/she no longer has the authority to represent you?
Yes No
Any report made to the police? Yes No
D. BANK ACCOUNT DETAILS (for direct transfer to your bank account)
Name (as per bank account)
Bank Name Bank Code
Account No. Branch Code
Email (for payment notification)
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] Where applicable, 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
(Please also provide Company Stamp for corporate policy)
F. DOCUMENTS REQUIRED FOR CLAIM ASSESSMENT & IMPORTANT NOTE
Below is a list of minimum documentation required to process your claim. Please retain an original copy of the supporting
documents listed below as they may be required for your claim. In certain circumstances, additional information may be
required in order for further confirmation.
(Please tick against the documents you have submitted)
Police Report/Police Investigation Result
Internal Investigation Report
CCTV footage showing circumstances of incident
Letter of Employment and Termination
Duty Roster of the employee(s)
Records supporting the amount claimed
Details of restitution made by the employee
Important :
• Give immediate notice to the police.
• To the extent allowed by law, retain all monies and other assets due to the Employee(s) and such monies or assets will
be deducted from the claim.
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.

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AXA INSURANCE PTE LTD

redefining insurance 8 Shenton Way #24-01 AXA Tower

Policyholder’s Full Name

Full Name (if different from policy holder)

Email Telephone No.

Is your company GST Registered? Yes No

Name of the Employee

Address of the Employee

Mobile No. of the Employee

Date of Employment Occupation

Remuneration Date of Termination

Yes No please provide details.

When was it discovered and by whom?

dates of such acts of fraud or dishonesty.

What were the Loss and Value?

there any checks and supervision in place?

No Yes please provide name of supervisor

No Yes please provide details.

Is there any other insurance covering the same loss?

No Yes please provide details.

Any money or property in your custody due or belongings to the employee?

No Yes please specify amount.

Do you know the present whereabouts of the employee?

No Yes please give precise details

No Yes please provide details.

Yes No please provide details.

Any report made to the police? Yes No

D. BANK ACCOUNT DETAILS (for direct transfer to your bank account)

Name (as per bank account)

Bank Name Bank Code

Account No. Branch Code

Email (for payment notification)

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

Date: ___________________________ Date: ____________________________

(Please tick against the documents you have submitted)

Police Report/Police Investigation Result

Internal Investigation Report

CCTV footage showing circumstances of incident

Letter of Employment and Termination

Duty Roster of the employee(s)

Records supporting the amount claimed

Details of restitution made by the employee

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Date: _ Date: __