SmartHelper Claim Form

SmartHelper claim form

A. Policy information

Policyholder's full name

Policy/Certificate no.

NRIC/FIN no.

Mobile no.

Home address

Name of patient (domestic helper)

Age

Sex

Date of employment

Work permit number

B. Sickness (This must be answered in full)

Diagnosis

Date symptoms first began

Date first treated

Is the sickness arising from employment?

Yes

Has the sickness been treated previously? If yes, please state name and address of physician.

Yes

Date of last treatment

Is the sickness due to pregnancy, abortion, sterilization or infertility? If yes, specify condition and approximate date of commencement.

Yes

Date of commencement

Name and address of hospital/clinic:

C. Injury

Date of loss/accident

Time of loss/accident

Is this a job related accident?

Yes

Name and address of hospital/clinic:

D. 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.

E. Employer & Patient’s Declaration

I / We confirm that I / We am the patient and the patient’s employer (respectively) and I / We declare that all the particulars given above are to the best of my / our knowledge true and correct. I / We hereby consent to and authorise the medical practitioner involved in the patient’s care to discuss and disclose treatment details, medical history 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. In connection with my / our claims, I / We give consent for HSBC Life (Singapore) Pte. Ltd(“HSBC Life”) 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, 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 related parties under this Policy) for the purpose of enabling HSBC Life and their respective representatives or agents to provide me / us with services required of an insurance provider, including the evaluating, processing, administering and / or managing my / our claims or this 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.

F. 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.

Thank you!

Thank you for your online Domestic helper claim notification. Our claims officer is reviewing your submission and will update your claim status in 14 days' time. Please quote our reference number when corresponding with us.

File a claim