Work Injury Claim

Work Injury Claim Form

Personal Information

Name of Policyholder*

NRIC*

Mobile Number*

Your Email*

Your Address*

Claims Payment

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.

Description of Claims

Date of accident*
Nature of Claim*
Description*

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

Name of insurance company/ other party *
Policy/ reference no *

Type of benefits*
Have you filed a claim?*
Amount claimed*

You have declared that you have not made any claim against any other party in respect of this event. *

I Agree

Upload Supporting Documents

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

I-Report made to MOM* (jpg, png, tif, gif, pdf, zip)

Photocopy of identity card and/or work permit* (jpg, png, tif, gif, pdf, zip)

In-house investigation report with coloured photos * (jpg, png, tif, gif, pdf, zip)

Original medical bills and/or certificates* (jpg, png, tif, gif, pdf, zip)

Pay slips to support the injured worker’s salary for the 12 calendar months prior to the accident (Earnings during the month of the accident and the month the injured employee joined cannot be considered)* (jpg, png, tif, gif, pdf, zip)

Medical report and/or inpatient discharge summary (if possible) (jpg, png, tif, gif, pdf, zip)

If the injured person is not your direct employee, please submit the relevant contracts to establish that the direct employer is your sub-contractor (jpg, png, tif, gif, pdf, zip)

If the injured person is your direct employee and injured at a project worksite, please submit all the relevant contracts relating to the project (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

1. 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.
2. 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.
3. 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.
4. 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;
5. 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;
6. 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.
7. 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.
8. agree and accept that ERGO Insurance reserves the rights to contact the institution directly for validation of any submitted medical document’s authenticity and can request for the original bill/certified true copies whenever necessary within 1 year from the date of receipt of such medical document.
9. understand and accept that ERGO Insurance can/may deny this or any related claims, recover any amounts disbursed, to impose additional charges or recovery any costs incurred in the event of fraudulent and/or multiple claims made.
10. [ Authorization ] Where applicable, I/ We hereby authorize any hospital, clinic, physician or any other person to disclose all information including copies of all hospital or medical records on the patient when requested by ERGO Insurance Pte. Ltd. (ERGO). I have noted that any illness, injury, consultations, medical history, prescriptions or treatment the medical report fee incurred will be borne by me. A copy of this authorization shall be considered as effective and valid as the original.

Please note that this procedure is only intended as a guide. Each claim submitted to ERGO will be reviewed based on its own merits in accordance with the concerned policy terms and conditions. We reserve our right to request for additional documents and/or information on a case-by-case basis.

Kindly note that it may take longer to process a claim if we require additional information or documents from you. For any claims enquiry, amendment of details or submission of supporting or original documents, please email our friendly claims officers at onlineclaims@ergo.com.sg with our policy number.

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.