Claim form								
Liability

This form is issued by Zurich Insurance Company Ltd. (Singapore Branch) (the “Company”) to enable the Insured to lodge a written statement of a claim for indemnity under the policy. It does not constitute admittance of a liability to indemnify.
Please note that all sections of the claim form are to be completed by the Insured and that failure to provide complete information may delay the processing of the claim.
If there is insufficient space on this form, please attach extra material as necessary.

   Important information 	
•  Do not admit liability - Ask for any claim to be put in writing and refer all correspondence to ZURICH INSURANCE COMPANY LTD (SINGAPORE BRANCH).
•  Make sure you give us all the details about your claim. Attach a separate sheet if you have insufficient space on this form.
  •  Send all quotations you have received to repair or replace damaged property or invoices or receipts if the goods have already been repaired. 

  Insured

Name

Business or Trading name

Policy number

Address                                                                                                                                                                                                 Postal Address 
Occupation
Contact name

Phone number – Private                                                 Business                                                   Mobile

Facsimile                                                                                                Email

Are you registered for GST purposes?           YES	        NO 
What is your Company Registration Number?
What percentage of the GST paid on the policy premium were you entitled to claim as an Input Tax Credit?	%

Please note that GST legislation requires that this information be provided when a claim is notified. However, it is not used in determining acceptance of a claim, nor will it be released to other parties.

Have you received a formal demand or claim from another person?   Yes            No

If 'Yes', has all correspondence including demands, contracts, quotes and invoices been attached?    Yes 	       No

Please note that any further correspondence or documentation received in relation to this claim should also be forwarded for attention.

     Goods and Services Tax

	

  Goods and Services Ta
  Details of Accident/Incident

Date	/	/	Time 	am/pm	Day

Location of incident/ accident

Please provide a description of the accident/incident. Attach a separate sheet if you have insufficient space on this form.

Please provide details of damaged property and/or injuries suffered

     Have you admitted responsibility/ liability for the incident?
      
       Yes            No

     Does the claim involve a product that you manufactured or supplied to another person? If 'Yes', please provide details
      
                    Yes           No

Were emergency services such as ambulance, police or fire brigade contacted?                                      Yes             No
If 'Yes', please provide details and attach reports if available

Did the accident or injury arise out of the use of a motor vehicle?                                                      Yes              No Was the motor vehicle registered or required to be registered?                                                                 Yes              No If unregistered, was the vehicle insured under a motor vehicle or other insurance policy?                        Yes              No Do you believe that another party or person is responsible?                                                                                    Yes          No
If 'Yes', please provide details
  Details of party or parties making claim against you

Name

Address 	

Phone number – Private	Business	Mobile

Lawyer's name

  Witnesses

Name

Address 	

Phone number – Private	Business	Mobile

Relationship (e.g. employee, family, friend, previously unknown) Name
Address 	

Phone number – Private	Business	Mobile

Relationship (e.g. employee, family, friend, previously unknown) Name
Address 	

Phone number – Private	Business	Mobile

Relationship (e.g. employee, family, friend, previously unknown) Name
Address 	

Phone number – Private	Business	Mobile

Relationship (e.g. employee, family, friend, previously unknown)

  Declaration
•	I / We hereby declare that all the information and particulars given above are true and complete to the best of my/our knowledge and belief and they are made without reservation of any kind.

•	I / We hereby acknowledge, consent and agree that –

i.	the Company may collect, use and disclose all personal data provided or as may be provided by me/us and through other sources as the Company deem relevant from time to time for the purposes as contemplated in this form including but not limited to policy servicing, processing, handling, administering, claims investigations, claims analysis, fraud evaluation, prevention and control, and/or any work put towards settling my/our claim with the Company or other insurers;  

ii.	the Company may disclose the personal data to third parties (whether in or outside Singapore) including but not limited to consultants, fraud detection agencies, the General Insurance Association and its members, regulators, law enforcement bodies and government agencies and/or authorities for the purposes as set out in this form; 

iii.	the personal data protection clauses herein (“DPC”) are not exhaustive. By signing this form, I/we declare that I/we have read, understood and agreed to be bound by the prevailing Personal Data Protection Policy available at http://www.zurich.com.sg/pdpa (“Data Protection Policy”) which is to be read together with the DPC. If there is any discrepancy between the DPC and the Data Protection Policy, the DPC shall prevail only to the extent of the discrepancy;     

iv.	if I / we provide third parties’ personal data (e.g. information of the life assureds, insured persons, beneficiaries, beneficial owners, dependents, spouse, children, parents, siblings, customers, prospects, payees and/or employees) to the Company, I / we represent and warrant to the Company that prior consents have been obtained from each of the third parties for the collection, usage, disclosure and processing of their personal data in the manner as set out above and the Data Protection Policy; and

v.	I / We shall indemnify the Company for all losses and damages which may be suffered by the Company arising out of the breach of the declarations, representations and/or warranties herein.

Name (Please print)    	

Signature (with company’s stamp, if applicable)	Date
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