Golf Claim Form

A. Policy information

Policyholder's full name

Policy/Certificate no.

B. Claimant details

Full name

Tick if Claimant is policy holder

NRIC/FIN no.

Membership number

Mobile no.

Email

C. Loss details

Place of loss/damage

Date of loss/damage

Time of loss/damage

Describe fully how it occured and the nature of loss or damage

D. Particulars of claim

Articles actually lost or stolen are to be described first.
Articles which have been damaged must also be described and shown after lost or stolen article descriptions.

Article #1

Description of lost/damaged item(s) (Brand, make & model)

Nature & extent of damage

Place of purchase

Date of purchase

Purchase price (SGD)

Cost of repair or replacement (SGD)

Deduction for age, use and/or wear & tear (SGD)

Amount claimed (SGD)

Add another entry

Total amount

Total amount (SGD)

E. Hole-in-one achievement

Date hole-in-one was achieved

Golf course at which hole-in-one was achieved

F. Personal accident and medical expenses

Nature of injury sustained

Body part injured

Amount claimed (SGD)

G. Liability to the public

Details of third parties

Detail #1

Name

Address

Nature of injury/Extent of damage

Add another entry

Has a claim been made upon you in respect of this accident?

Yes

No

If yes, what is the amount claimed (SGD)

Have you in any way admitted liability?

Yes

No

If yes, please state reason:

Was the accident contributed to or caused by negligence on the part of the third party?

Yes

No

If yes, in what way was the third-party negligent?

H. Other Insurance/Information

Is there any other insurance covering this incident?

Yes

No

If yes, please state name of insurance company

Policy number

I. Bank account details

Please provide your bank details for us to accelerate your claims payment process by direct transfer to your bank account.

Name (as per bank account)

Bank code

Bank name

Branch code

Account no.

J. 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] 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 HSBC Life (Singapore) 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 HSBC Life (Singapore) Pte. Ltd. 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 HSBC 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 HSBC Life 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 HSBC Life (as the case may be), and for the purposes set out in HSBC Life’s Data Privacy Policy which can be found at insurance.hsbclife.com.sg (“Purposes”).

I, the claimant agree to abide by the terms & conditions.

K. Documents required for claim assessment

Below is a list of minimum documentation required to process your claim. In certain circumstances, additional information may be required in order for further confirmation.

Documents required (please tick against the documents you have submitted)

Colour photograph of the damaged item(s)

Repair/Replacement receipts

Police report/Incident report from the club

Original bills/F&B bill/Scorecard/Hole-in-one certificate

Original medical bills/Medical report, if applicable

L. Final steps

Upload supporting documents
Please attach the relevant supporting documents with your claims submission to expedite claim processing.

Other

Please type what you see in the image:

Please review and ensure all details are accurate before you proceed.

File a claim