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Student Accident Protection Scheme - On_Line Reporting

  • Kindly fill up all the details
  • Use the 'Tab' key or mouse to go to next field instead of 'Enter' key
  • send us all the Original Invoices after the last checkup
  • Refer to Frequently Ask Question for more details
Name of Student/NRIC
Home Address
Unit No
Postal Code
Phone Number
Email Address
for us to revert to you
Name of School
Class/Date of Birth/Gender
Date/Time of Accident
Place of Accident
Description of Accident
(when & How)
Description of Injury
(which part & type of Injury)
Name of Hospital/Clinics :
Cheque Payee :
Address(if different from above) :
Unit No :
Postal Code :

Remarks
DATA PRIVACY STATEMENT AND DECLARATION In accordance with the Personal Data Protection Act 2012, I/We consent to the collection, use, disclosure of and/or process my/our personal data (whether contained in the Claim Form or otherwise obtained) by Lonpac Insurance Bhd (”Lonpac”), 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/us by Short Message Service (SMS), Multimedia Messaging Service (MMS) and fax messages (notwithstanding the registration of my/our telephone number(s) in the Singapore’s Do Not Call Registry).

Yes, I/we have read and agreed to the above Data Privacy Statement and I declare that the information shown in this form is true and correct to the best of my knowledge.
Name of Claimant/Parent/School Representative
Nric/Passport No

Please print a copy for your record before submission

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