General claims

Name

Address

Unit No

Postal Code

Phone Number

Email Address

Date of Birth

Date of Accident

Time of Accident (HH:MM)

Place of Accident

Description of Accident
(When & How?)

Remarks

Data privacy statement and declaration

I consent to the collection, use, disclosure of and/or process my personal data (whether contained in the Claim Form or otherwise obtained by bolttech Insurance Broker, its affiliates and service providers (within or outside Singapore), for the purpose relating to the evaluation of the claim and to provide advice and information relating to the claim to me any form of communication medium (notwithstanding the registration of my telephone number(s) in the Singapore’s Do Not Call Registry).

I have read and agreed to the above Data Privacy Statement and declare that the information shown in this form is true and correct to the best of my knowledge.

Name of Claimant:

NRIC/FIN: