Apply for Hospitalization Claim

Name as in NRIC

NRIC

Residential Address

Telephone (Residential)

Telephone (Office)

Mobile Phone

Bank Account No.

Bank Name

Nature of Illness

Days Hospitalised

From

YYYY

I hereby agree that the personal particulars provided in this application may be used by the Society from time to time and in compliance with all applicable laws on data privacy to disclose your personal data to any SGSCC personnel, related vendors and agencies.

You are assured that when we disclose your personal data to such parties, we require them to ensure that any personal data disclosed to them are kept confidential and secure.

Yes

Upload Tax Invoice/ Discharge Summary

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DECLARATION

By clicking on 'Submit', I declare the following:

I read the rules and regulations with regard to the Hospitalisation Benefits Scheme.

I confirm that the information given is FULL,TRUE and CORRECT.

The Society shall have the authority to recover the sum paid to me should there be any information found which disqualify the claim.

I hereby authorise my surgeon or physician to release any information with regard to my hospitalisation to the Society.

(*Please send your Hospitalisation Bill / Discharge Summary via Email to admin@sgscoop.sg)