Domestic Maid Medical Claim

Please complete the Domestic Maid Medical Claim Form that is available in our website and mail it to ERGO Insurance Pte. Ltd together with the following supporting documents:

Medical report or inpatient discharge summary
Original medical bills and certificates (not applicable for outpatient claims)
Referral letters (if any)
A copy of the maid’s work permit
A copy of the contractual agreement between you and the maid, stating the maid’s monthly salary (not applicable for outpatient claims)
Monthly levy to MOM (not applicable for outpatient claims)

For Claims below $200 (Original documents are not required), please submit through our website, Or email to claims@ergo.com.sg

Domestic Maid Medical Claim Form

Simply submit your claims via our online claim portal by following simple steps indicated below.

*Note: Each claim is unique and will be assessed based on its merit. We would, from time to time, request further information from you, for us to assess your claim. You do not need to send us original documents, however we require you to keep all original documents for 6 months from the date of submission, in the event we need to sight them. We would like to remind you, that we will deny claims that are either dishonest or of fraudulent nature, and such claims will be referred to the appropriate authorities.

Personal Information

Policy Number*

Name of Policyholder*

Name of Claimant*

NRIC*

Mobile Number*

Your Email*

Your Address*

Claims Payment

Name of Bank*

Bank SWIFT Code*

Account Number*

Account Holder's Name*

Please provide your bank details for faster claims processing. Once approved, your claim amount will be credited into your bank account.

We will only credit into the Policyholder’s/Insured Person’s account.
Notification of payment will be sent to your email address stated in your details. The company shall:
(i) be discharged from all liability under this claim and
(ii) not be liable for any and all losses incurred by you, as a result of you providing the company with inaccurate bank account number under this section for the payment of this claim.

Upload Supporting Documents

If your medical claim value is above SGD$200, Please mail your original documents to Claims Department. For all other claims types You do not need to send us original documents, however we require you to keep all original documents for 6 months from the date of submission, in the event we need to sight them.

Claim Form* (jpg, png, tif, gif, pdf, zip) Please download, complete claim form and upload here

Medical report or inpatient discharge summary* (jpg, png, tif, gif, pdf, zip)

Copy of maid's work permit* (jpg, png, tif, gif, pdf, zip)

Original medical bills and certificates (not applicable for outpatient claims) (jpg, png, tif, gif, pdf, zip)

Referral letters (if any) (jpg, png, tif, gif, pdf, zip)

Copy of contractual agreement between you and the maid, stating the maid’s monthly salary (not applicable for outpatient claims) (jpg, png, tif, gif, pdf, zip)

Monthly levy to MOM (not applicable for outpatient claims) (jpg, png, tif, gif, pdf, zip)

Any other supporting document (1) (jpg, png, tif, gif, pdf, zip)

Any other supporting document (2) (jpg, png, tif, gif, pdf, zip)

Declaration and Submission

By submitting this claim form online, you:

declare that the particulars stated above are true, accurate and complete and understand that if you have in this or in any further declaration in respect of this claim, made any false or fraudulent statement or suppress conceal or falsely state any material fact whatsoever my claim may be refused.
authorise any person or organisation who has relevant information on this claim, including any medical practitioner, health care provider, insurance company and investigative agencies, to release and exchange such information (including personal health information) requested by ERGO Insurance and/or its claims service providers.
authorise ERGO Insurance and its claims service providers to collect, use, disclose and/or process your personal data set out in this form and any other information provided by you or possessed by ERGO Insurance for the purpose of enabling ERGO to provide you with services required of an insurance provider, such as evaluating, processing, administering, and/or managing of your relationship and policies with ERGO Insurance. This includes among other things policy servicing, processing, investigating, handling, administering and/or settling your claim with ERGO or other insurers.
understand that ERGO Insurance may/will disclose and transfer your personal data to third parties, including but not limited to its affiliates, representatives, agents and third party service providers, lawyers/law firms, whether located within or outside Singapore, for one or more of the above purposes, and the said third parties may/will subsequently collect, use, disclose and/or process your personal data for or more of the above purposes;
accept that the personal data protection clauses herein are not exhaustive and you have read, understood and accept the terms of ERGO’s Personal Data Protection Policy at https://www.ergo.com.sg/pdpa;
confirm that you are authorised to disclose information (including personal health information) about the insured person if this claim is made on behalf of them.
confirm that you or the insured person is not claiming from any other insurance policy or on your or insured person's employment benefits provided by your or insured person’s employer.

I Agree

Imp Note: The acceptance of this online claim form does NOT constitute an admission of liability by ERGO Insurance Pte Ltd. or waiver of its rights.

For Enquiries

ERGO Insurance Pte. Ltd.

Email: claims@ergo.com.sg
Phone: +65 6829 9199/ +65 98276193 (office hours)
Fax: +65 6829 9247

Domestic Maid Medical Claim

Domestic Maid Medical Claim