HAJJ EMA TAKAFUL 1440H

Follow up treatment in Singapore within 7 days from date of return (for illness afflicted while in Saudi Arabia or whilst enroute back to Singapore).
ONLY FOR SINGAPORE HAJJ PILGRIMS 1440H

Full Name of Claimant*

Proposal No.

Contact No.*

Passport No.*

Travel Agent*

Address*

Date of Clinic/Hospital Visit*

Date of Arrival to Singapore*

Amount to claim*

Payment options*

*Bank Transfer - Please furnish your Bank and Account details

Options: OCBC/MAYBANK/UOB/STANDARD CHARTERED

Remarks*

Please scan or snap a photo of the following documents required

First consultation page of the Green Book
Original copy of itemised Medical Receipt
Original copy of Hospital Discharge Summary (if applicable)

NOTE: Please retain the original documents for claim purpose.

Upload*

Limit per file: 10MB

Important Notice

In accordance to the provisions of the Personal Data Protection Act 2012 (“PDPA”), the UOI’s privacy notice shall form part of the terms and conditions of the Policy. A copy of UOI’s Privacy Notice can be found at www.uoi.com.sg

DECLARATION

I declare that the information given in this form is true and correct to the best of my knowledge and belief.

I hereby authorise any hospital physician, other person who has attended or examined me, to furnish to the company, or its authorised representative, any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A photo static copy of this authorisation shall be considered as effective and valid as the original.

Signature*