WIC Claim Form

Work Injury Compensation Claim Form
The acceptance of this Form is NOT an admission of liability on the part of HL Assurance Pte. Ltd.. Any documentary proof or report required
by HL Assurance Pte. Ltd. shall be furnished at the expense of the Policyholder or Claimant.
PARTICULARS OF INSURED
Name of Company Policy No.
Nature of Business Period of Insurance
Address of Company Is your Company GST registered?
Total No. of Employees Name of Intermediary (if any)
Tel. No. Fax No. E-mail
PARTICULARS OF INJURED WORKER

Is the injured in your direct employment? Yes No
Name (as in NRIC/Passport/Work Permit) Nationality
If not, please give the name and address of his direct
employer.
NRIC/Passport/Work Permit No. Marital Status
Gender Male Female Occupation Was the injured free from any physical defect or infirmity
at the time of accident? Yes No
If no, please provide details.
Date of Birth No. of working days per week
Address Date of Employment Would such physical defect or infirmity have contributed
towards this accident? Yes No
If yes, please provide details.
DETAILS OF ACCIDENT (PLEASE COMPLETE ALL QUESTIONS)

Date of accident Time of accident Location of accident (please specify the country if it is outside Singapore)
When did you receive notice of accident and from whom?
When did the injured actually cease work?
Explain fully how did the accident occur (if machinery is involved, state the type of machinery).
What was the general nature of the work or contract going on when the accident occurred?
State the names and contact numbers of any witnesses to the accident.
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Was the injured under the influence of alcohol or drugs at the time of accident? Yes No
Was the injured guilty of any misconduct or disobedience to orders or rules? Yes No
Did this accident occur as a result of another person’s negligence? Yes No

Are you satisfied that the injured has met with a bonafide accident of employment? Yes No
Was this accident reported to Ministry of Manpower? Yes No

If yes, please attach a copy of i-report.
If no, please provide reason of non-reporting.
Did the injured met with any previous injury under your employment? Yes No
DETAILS OF INJURY
State the name of hospital/clinic where the injured received treatment.
Please provide details of injuries sustained, indicating the injured body part and nature of injury.
Was the injured hospitalised? Yes No

If yes, please provide a copy of the inpatient discharge summary.
Did the injured attend any outpatient treatment after the accident? Yes No
If yes, please provide name of hospital/clinic.
How many days of Medical Leave was the injured given from the time of accident?
(a) Hospitalisation Leave: _______________________________ (b) Outpatient Leave: __________________________________
Has the injured returned to work? Yes No

If yes, please advise when ______________________________________________________________
If no, please provide the probable period of disablement _______________________________________
Is the injured able to do partial work? Yes No
EARNINGS OF INJURED WORKER

(GROSS MONTHLY EARNINGS DURING THE 12 MONTHS PRECEDING THE DATE OF ACCIDENT)
GROSS MONTHLY EARNINGS ANNUAL WAGE SUPPLEMENT / BONUS
MONTH NO. OF WORKING DAYS
(EXCLUDING BONUS) PAID DURING LAST 12 MONTHS
TOTAL
TOTAL MONTHLY AVERAGE
TOTAL DAILY AVERAGE
Ver 1.1
IMPORTANT NOTICE
1. Insured is requested to complete the form as fully and accurately as possible the information asked for as per above.
2. If any detail or information is not readily available, please do not delay the submission of this claim form and supply the missing detail or
information as soon as possible.
3. Please submit the following:
(a) Original Claim Form duly completed and signed;

(b) Copy of i-report submitted to Ministry of Manpower;
(c) Police report (if applicable);
(d) Original medical bills/receipts and certificates;
(e) Copy of NRIC/Passport/Work Permit (with photo shown);
(f) Copies of detailed wage payment vouchers of the injured (12 months preceding the date of accident);
(g) Copies of detailed wage payment vouchers during the period of Medical Leave;
(h) Copy of death certificate, if the accident resulted in death of employee; and
(i) Copies of all your correspondences exchanged between you and Ministry of Manpower and/or all third party correspondences.
4. According to the Work Injury Compensation Act, each and every accident occurred to your employee(s) at work must be reported
to the Ministry of Manpower through i-report within 10 days of the occurrence of the accident:
* where it results in death of an employee; or

* where it renders an employee unfit for work for more than 3 consecutive days or hospitalised for at least 24 hours; or
* where the employee has contracted an occupational disease.
Failure to report a work-related accident is an offence which carries a fine of up to S$5,000 for a first-time offence and a fine up of up to
S$10,000 and/or a jail term of up to 6 months for subsequent offences.
5. In the case of a fatal accident, please inform us the date, time and place of Coroner Inquiry when it is made known to you and provide us
with a copy of death certificate and post mortem report respectively.
6. If the accident is a subject of claim under Common Law, please forward to HL Assurance Pte. Ltd. all correspondences that you have
received, or may receive, from the lawyer(s) of injured and you must not, in any circumstances, admit liability whatsoever in any manner,
be it verbal or in writing.
DECLARATION
AUTHORISATION FOR MEDICAL REPORT (TO BE COMPLETED BY THE INJURED WORKER)
I hereby authorise any hospital doctor or other person who has attended to me to furnish HL Assurance Pte. Ltd. or its representatives any and all
information with respect to any sickness or injury, medical history, consultation, prescription or treatment and copies of all hospital or medical records.
I agree that a photocopy of this authorisation shall be considered as effective and valid as the original.
Name _______________________________________________________ Signature ____________________________________________
NRIC/Passport/Work Permit No. __________________________ Date _____________________________
I/We declare that the above information is true and correct to the best of my/our knowledge and belief, and I/we claim in respect thereof the protection
of my/our policy. I/We accept that insurers would be at liberty to deny liability in part or in full if the above written answers are false or inaccurate in
any aspect.
Insured’s signature (with Company’s stamp) __________________________ Name & Designation ___________________________________
NRIC/Passport No. ______________________________ Date _____________________________
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Work Injury Compensation Claim Form

Name of Company Policy No.

Nature of Business Period of Insurance

Address of Company Is your Company GST registered?

Total No. of Employees Name of Intermediary (if any)

Tel. No. Fax No. E-mail

PARTICULARS OF INJURED WORKER

DETAILS OF ACCIDENT (PLEASE COMPLETE ALL QUESTIONS)

When did you receive notice of accident and from whom?

When did the injured actually cease work?

Did this accident occur as a result of another person’s negligence? Yes No

Was this accident reported to Ministry of Manpower? Yes No

Was the injured hospitalised? Yes No

Has the injured returned to work? Yes No

Is the injured able to do partial work? Yes No

EARNINGS OF INJURED WORKER

3. Please submit the following:

(a) Original Claim Form duly completed and signed;

* where it results in death of an employee; or

Name _______________________________________________________ Signature ____________________________________________

NRIC/Passport/Work Permit No. __________________________ Date _____________________________

NRIC/Passport No. ______________________________ Date _____________________________

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Name ___________ Signature

NRIC/Passport/Work Permit No. Date ___

NRIC/Passport No. __ Date _