1. Health Claim Application Requirement
2. Incapability Claim Application Requirement
3. Death Claim Application Requirement
4. Critical Disease Application Claim Requirement
5. Claim Application Form

 If you need further explanation, please contact our hotline number (021) 7279 2807
 

Health Claim Application Requirement

1. Hospital Care Claim Form (filled by the insured in treatment, or if insured age is under 18 years old, the form can be filled by the policy holder)
2. Doctor statement for Hospital Care Claim (filled by the doctor that performed treatment to the insured)
3. Customer reinstates the two forms that have been filled properly, which is:

• Receipt and payment evidence of hospital care (original or legalized copy)
• Details of the name and price of the medicine that is used during treatment (original or legalized copy)
• Details of name / type and price of medical tools that is used during treatment (original or legalized copy)
• Details of name/ type and price of laboratory examination, X-ray, and other check up that is used during treatment (original / legalized copy)
• Details of type and other cost which is included in the receipt, in order to confirm that the whole amount fit the total cost that is written in the receipt given to PT. AXA Mandiri Financial Services (original or legalized copy).
• esult of support check up (laboratory, X-ray, CT-scan, USG and other check up) which being done by customer during treatment.

 Incapability Claim Application Requirement
(Accident Protector, Premium Protector, Payor Protector)

1. Incapability/Disability Claim Form (filled by Insured /Policy Hodler)
2. Doctor statement for Incapability/Disability Claim (filled by doctor who performed treatment)
3. Customer / FA reinstates the two form that have been filled properly to the Claim division, which is:

• All laboratory checkup result, Radiology and other check up that the insured did (original or legalized copy)
• Evidence Report /Police Statement, for the case that involve the police (original or legalized copy).

 Death Claim Application Requirement

1. Death Claim Statement Application Form (filled by the beneficiary or by the guardian if the beneficiary is still under 17 years old)
2. Doctor statement letter (filled by the doctor who performed treatment to the insured
3. Beneficiary / FA reinstates the two form that have been filled properly and submit to the Claim division, which is:

• Original policy
• Last premium payment receipt – original
• Identification card of the insured – original or legalized copy
• Identification card and birth certificate of the beneficiary – original or legalized copy
• Family Card - original or legalized copy
• Death statement letter from the civil service – original or legalized copy
• Death certificate from the authority - original or legalized copy
• Letter of funeral evidence from the funeral service or letter of crematorium evidence from the authority - original or legalized copy
• Evidence Report /Police Statement, for accident cause or uncommon death - original or legalized copy
• Visum et Repertum Letter from the doctor in charge for sudden death with accident cause or uncommon death - original or legalized copy
• If the insured died outside of Indonesia, the statement letter of death must be legalized by Indonesia Embassy or local authority

Critical Disease Application Claim Requirement

1. Critical Disease Claim form (filled by insured)
2. Doctor statement form for Critical Disease Claim (filled by the doctor who performed treatment to the insured).
3. Customer reinstates the two form that have been filled properly and submit to the Claim division, which is:

• All laboratory checkup result, Radiology and other check up that the insured did (original or legalized copy) according to the requirement to confirm critical disease
• Evidence Report /Police Statement, for the case that involves the police (original or legalized copy).
• Other statement letter or other document that is considered necessary for the insured.

Claim Application Form

• Formulir Klaim Ketidakmampuan / Cacat
• Formulir Klaim Penyakit Kritis (Critical Illness)
• Formulir Klaim Perawatan di Rumah Sakit
• Pernyataan Pengajuan Klaim Meninggal
• Pernyataan Dokter untuk Klaim Ketidakmampuan Cacat
• Pernyataan Dokter untuk Klaim Penyakit Kritis (Critical Illness)
• Pernyataan Dokter untuk Klaim Perawatan di Rumah Sakit
• Surat Keterangan Dokter untuk Klaim meninggal

Syariah Claim Application form

• Surat Keterangan Dokter untuk Klaim Penyakit Kritis
• Formulir Klaim Penyakit Kritis
• Surat Keterangan Dokter untuk Klaim Rawat Inap
• Formulir Klaim Rawat Inap
• Surat Keterangan Dokter untuk Klaim Ketidakmampuan
• Formulir Klaim Ketidakmampuan
• Surat Keterangan Dokter untuk Klaim Meninggal
• Formulir Klaim Meninggal