Msig Dental Claim Form
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2MSIG Insurance (Singapore) Pte. Ltd.
(Co. Reg. No. 200412212G)
4 Shenton Way, #21-01,
SGX Centre 2, Singapore 068807
Claim Hotline +65 6827 7660 (24 hours) Fax +65 6225 6371
DENTAL CLAIM FORM
Policy Number
Please note that this form is issued without admission of liability. Please state all relevant information requested as complete and as accurate as possible.
Particulars of Insured
*
*
Name of Insured (As in NRIC/Passport)
NRIC/Passport/BC Number
Gender
Male
Female
Home Address
Date of Birth
(dd/mm/yyyy)
+
Contact Person
Occupation
Contact Number
Email
(H)
(O)
(HP)
+ If applicable
*
Delete if not applicable
Details of Claim
DENTAL CONDITION / INJURY
Nature of Dental Condition / Injury and Final Diagnosis
Date Symptoms First Started
Date First Treated
(dd/mm/yyyy)
(dd/mm/yyyy)
Attending Doctor’s Name and Address
Has the condition been treated previously?
Yes
No
If Yes, please state Name and Address of the Dentist for previous treatment:
Date of previous treatment
(dd/mm/yyyy):
OTHER INSURANCE OR COMPENSATION
Was a third party involved?
Yes
No
If Yes, please state whether reimbursement or other compensation will be provided.
Is the Insured/Claimant claiming from another Insurance Company/other sources?
Yes
No
If Yes, please provide a copy of their settlement details.
Supporting Documents
1. Original final detailed hospital bills or receipts
2. Original final clinic bills or receipts
Medical Authorisation (This Portion Must Be Completed By The Claimant)
I hereby authorise any hospital physician or other person who has attended or examined me to furnish to the Insurer or its representative any
and all information on my illness, injury, medical history, consultations, prescriptions or treatment, with copies of all hospital or medical
records. A photocopy of this authorisation shall be considered as effective and valid as the original.
Please make the cheque payable to
Signature of Claimant
Name of Claimant
Declaration
I/We declare that the information given is true and correct to the best of my/our knowledge and belief. I/We understand that any false or
fraudulent statements or any attempt to suppress or conceal any material facts shall render the policy void and I/we shall forfeit my/our
rights to claim under the policy.
Signature of Insured
Name
Date
(dd/mm/yyyy)
CLM-DEN-0213
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