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SPEEDY CLAIMS PROCESSING

COMPLETE PEACE OF
MIND WHEN YOU CLAIM

Workmen Compensation Claim

IMPORTANT STATEMENT - You are to disclose in this claim form, fully and faithfully all the facts which you know or ought to know, otherwise the claims issued hereunder may be invalidated.

Policy
Verification

Personal
Information

Claim
Selection

Claim
Information

Document
Upload

Claim
Summary

Payment
Details

Claim
Submission

PLEASE ENTER THE FOLLOWING DETAILS FOR VERIFICATION PURPOSES:

POLICY NUMBER *

IC OR COMPANY REG. OR PASSPORT NUMBER *

I/We agree to disclose in this claim form to National Insurance Company Berhad, fully and faithfully all the facts which I/we know or ought to know, otherwise the claims issued hereunder may be invalidated.

POLICY NUMBER

POLICY HOLDER NAME

CONTACT PERSON/PERSON-IN-CHARGE *

CONTACT NUMBER *

EMAIL ADDRESS *

PLEASE MAKE YOUR CLAIM SELECTION, BELOW:

EMPLOYEE PROTECTION CLAIM

WORKMEN COMPENSATION CLAIM

FOREIGN DOMESTIC HELPER PACKAGE CLAIM

PLEASE REVIEW THE LIST OF DOCUMENTS THAT YOU ARE REQUIRED TO PREPARE FOR UPLOAD, FOR THIS CLAIM

PLEASE COMPLETE ALL INFORMATION FOR WORKER, BELOW:

WORKER'S NAME *

IS THE WORKER A LOCAL OR A FOREIGNER? *

LOCAL FOREIGNER

IC NUMBER *

PASSPORT NUMBER *

OCCUPATION *

WORKER'S ADDRESS LINE 1 *

WORKER'S ADDRESS LINE 2

POSTAL CODE

CONTACT NUMBER

EMAIL ADDRESS

PLEASE SELECT & COMPLETE ALL DETAILS BELOW:

SELECT TYPE OF CLAIM *

INJURY

SICKNESS

DEATH

SELECT TYPE OF INJURY *

WORK RELATED INJURY

NON-WORK RELATED INJURY

DATE OF INCIDENT (DD/MM/YYYY) *

TIME OF INCIDENT (24HR FORMAT) *

LOCATION/PLACE OF INJURY *

CAUSE OF DEATH *

PLEASE ENTER THE DETAILS OF HOW THE INJURY OCCURRED *

Characters: 0/2000

HAS THE INCIDENT BEEN REPORTED TO THE POLICE?

If YES, please upload the Police report and/or statement, listed under the ‘Upload Documents’ section.

No.

HAS THE WORKER RECEIVED MEDICAL TREATMENT?

If YES, please upload all Medical documents, listed under the ‘Upload Documents’ section.

No.

HAS THE WORKER RETURNED TO WORK?

Yes

WAS THE INJURED WORKER UNDER THE INFLUENCE OF INTOXICATING LIQUOR OR DRUGS AT THE TIME OF THE INJURY?

Yes

HAS THE INJURY BEEN REPORTED TO THE COMMISSIONER OF LABOUR AND/OR SHENA?

Yes

IS REPATRIATION OF THE WORKER TO THEIR HOME COUNTRY REQUIRED?

Yes

REPATRIATION COUNTRY *

								PLEASE UPLOAD YOUR FILES, WHICH SHOULD BE IN EITHER JPG, PNG OR PDF FORMAT. EACH INDIVIDUAL FILE SIZE SHOULD NOT EXCEED 3MB.
								
ALL DOCUMENTS MARKED WITH * ARE MANDATORY

UPLOAD DOCUMENT (WORKERS IC FRONT & BACK) *

UPLOAD DOCUMENT (WORKERS PASSPORT) *

UPLOAD DOCUMENT (LD OR AMAH QUOTA FOR THE FDH CLAIM) *

UPLOAD DOCUMENT (LABOUR CONTRACT AGREEMENT)

UPLOAD DOCUMENT (FORM A TO LABOUR DEPT.)

UPLOAD DOCUMENT (SALARY VOUCHERS / MINIMUM PAST 3 MONTHS) *

UPLOAD DOCUMENT (ORIGINAL MEDICAL RECEIPTS) *

UPLOAD DOCUMENT (MEDICAL REPORT)

UPLOAD DOCUMENT (MEDICAL DISCHARGE TICKETS)

UPLOAD DOCUMENT (REPATRIATION BILLS/INVOICES) *

UPLOAD DOCUMENT (DEATH CERTIFICATE COPY) *

UPLOAD DOCUMENT (AUTOPSY REPORT)

UPLOAD DOCUMENT (FUNERAL EXPENSES)

UPLOAD DOCUMENT (POLICE REPORT) *

UPLOAD DOCUMENT (OTHER RELEVANT DOCUMENTS)

						PLEASE REVIEW YOUR EMPLOYEE PROTECTION CLAIM SUBMISSION, BELOW.
						IF YOU WISH TO MAKE ANY AMENDMENTS, PLEASE CLICK ‘CHANGE' TO MAKE THE NECESSARY CHANGES, THEN RE-SUBMIT.
						

IF YOU WISH FOR PAYMENT TO BE MADE TO YOU VIA ONLINE TRANSFER, KINDLY PROVIDE US WITH YOUR BANK ACCOUNT DETAILS AS FOLLOWS:

BENEFICIARY BANK NAME

OTHER BENEFICIARY BANK NAME

BENEFICIARY NAME *

BENEFICIARY BANK ACCOUNT NUMBER

BENEFICIARY ADDRESS

BENEFICIARY BANK SWIFT CODE

Declaration

Please note that you are submitting this claim to National Insurance Company Berhad. Please see our full Terms of Conditions and Privacy Policy.

By submitting this claim to us, you are deemed to have agreed to us collecting, using, disclosing and processing your personal data for the purpose of assessing your claim. This may include disclosing and sharing your personal data with our service providers and/or with other insurers in the general insurance industry, including BDCB, for the proper processing, handling and/or dealing with your claim, which includes investigating the said claim and complying with applicable laws (collectively, 'the Purpose'). We may also need to disclose or share your personal data with service providers who are sited outside Brunei for the Purpose.

I declare that the information given is true and correct to the best of my knowledge and belief. I understand that any false or fraudulent statements or any attempt to suppress or conceal any material facts shall render the policy void and National Insurance Company may refuse to pay the claim.

Compensation due to employee's injury.

As an employee you were given leave (MC or Hospitalisation leave) or light duties as a result of your sickness.

As an employee you wish to claim compensation for a work related injury.

As an employee you wish to claim compensation for a non-work related injury.

Compensation due to employee death.

Employee Protection Claim: A claim for any local or foreign employee who is under a contract of service or contract of apprenticeship, regardless of salary, age or citizenship.

Workmen Compensation Claim: A claim for compensation against the employer, as a result of injury, sickness or death sustained at the workplace.

Foreign Domestic Helper Package Claim: A claim if an amah, driver or gardener become injured or hospitalised due to illness or an unfortunate accident at home.

Location of the accident (please name the Kg area)
Example: Gadong area (in front of the Lexus / NBT)

Claim submission is in-progress.

PLEASE ENSURE THAT FOLLOWING DOCUMENTS IN EITHER JPG, PNG OR PDF FORMAT ARE PREPARED & READY TO BE SUBMITTED AS PART OF YOUR ONLINE CLAIM SUBMISSION. EACH INDIVIDUAL FILE SIZE SHOULD NOT EXCEED 3MB.

Copy of Identity Card/Passport
Copy of Form A (to the Labour Department)
Copy of Salary Vouchers/Past 6 months
Copy of Medical Receipts
Copy of Medical Reports (if any)
Copy of Medical Discharge Tickets (if any)
Copy of Death Certificate (Incase of death)
Copy of Autopsy Report (Incase of death) (if any)
Copy of LD or Amah Quota for FDH (for foreigners)
Copy of Labour Contract Agreement (for foreigners)
Copy of Repatriation Bills/Invoices (if any) (for foreigners)
And any relevant documents relating to your respective claim submission