File a claim

File a claim
File a claim

Work injury compensation claim form

A. Policy information

Policyholder's full name

Policy/Certificate no.


Telephone no.

Total no. of employees

Is your company GST registered?

B. Claimant details

Full name


Mobile no.


Date of birth


Date of employment

Is the claimant in your direct employment? if not please provide the name and address of direct employer

No. of working days per week

Average monthly earnings (12 months before the accident) (SGD)

C. Accident details

Date of accident

Time of accident

Location of accident

Is this a project site? if yes please provide main contractor name

Description of accident

Description of injury sustained (e.g. body part injured, injury type)

Are you satisfied the injured has met with a bona fide accident arising out of his/her employment?

Please provide details:

Was the injured under the influence of alcohol or drugs at the time of accident?

Please provide details:

Type of medical treatment

Name of hospital/clinic taken to

Has the claimant returned to work?

Please provide details:

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. 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 (“Purposes”).

F. 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)

G. Final steps

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

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

Thank you!

Thank you for your online Work injury compensation 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.