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Hospitalisation claim form 

1. Notice Of Claim 

Written notice of claim must be given to AXA Life within 30 days after the occurrence of any medical treatment 

covered by the policy. 

2. Claim Documents 

The Assured shall, at his own expense, furnish all original documents, hospital bills and any medical evidence to AXA 

Life together with a fully completed claim form (refer to point 3 Claim form). 

Please submit a copy of the Assured’s NRIC and a copy of the Life Assured’s NRIC or birth certificate. 

If required, we may ask for further documents to be provided after our initial assessment of the claim. 

3. Claim form 

The attached claim form consists of three (3) parts : 

3.1 Part I Claimant’s Statement (Page 2 to 4) 

This is to be completed by the Assured of the policy. Please ensure that this form is fully completed, signed 

(in the same manner as that in our record) and dated. 

3.2 Part II Attending Physician Statement (Page 5 to 7) 

To be completed and signed by the Attending Physician. Please note that the fee for completion of the 

Attending Physician Statement (if any) shall be borne by the Assured. 

3.3 Part III Clinical Abstract Application form (Page 8) 

To be completed and signed by the Life Assured. Should the Life Assured be less than 21 years old, this 

form shall be completed by the parent or legal guardian of the Life Assured. Please ensure that this form 

is fully completed, signed, dated and witnessed. 

4. Submission of Claim Form 

You can submit the duly completed claim form, relevant medical reports, laboratory or diagnostic results, original final 

hospital bills and receipts required for assessment of the claim: 

4.1 through your adviser or 

4.2 directly to AXA Life Insurance Singapore Pte Ltd – Life Operations (Claims) 

5. Contact us 

Should you have any queries, please contact your adviser, or our customer service officers at our hotline at 1800 325 

4462, between 8.30am to 5.30pm from Monday to Friday. You can also send us a fax at 6880 5501 or email us at 

comsvc@axa.com.sg for assistance. 

AXA Life Insurance Singapore Pte Ltd (Company reg. no. 199903512M) 

8 Shenton Way #27-02 AXA Tower Singapore 068811 

AXA Customer Centre #B1-01 Tel: 6880 5500 Fax: 6880 5501 

Website: www.axalife.com.sg 

Hospitalisation claim form / Mar 11 Page 1 of 8

Part I: Claimant’s statement - Hospitalisation Claim Form 

Type of benefits you are claiming: 

Premier Care Prime Care Hospital Benefit rider Others (please specify): ___________________________ 

Policy No. : (1) _________________________ (2) ___________________________ (3) _______________________________ 

Assured’s Details: 

Name : _______________________________________ 

Contact No. : __________________________________ 

NRIC no. : _______________________________________________ 

Occupation : ______________________________________________ 

Current Address : _________________________________________________________________________________________ 

Life Assured’s Details (if other than Assured): 

Name : ________________________________________ Relationship with Assured : __________________________________ 

NRIC no. : _____________________________________ Occupation : _______________________________________________ 

This claim is submitted to AXA Life through : self my current servicing adviser 

[A] 

Details of hospitalisation or surgery 

1. Period of hospitalisation: 

Date admitted : ________________________ 

Date discharged : ____________________________ 

2. Were the Life Assured admitted to the Intensive Care Unit? Yes No 

If yes, please state: 

Date admitted : ________________________ 

Date discharged : ____________________________ 

3. Diagnosis: 

(a) Fully describe fully the symptoms for which the Life Assured consulted a doctor. 

__________________________________________________________________________________________________ 

(b) Date of which the symptom(s) first commenced (dd/mm/yy) : _________________________________________ 

(c) Date when the Life Assured first consulted a doctor (dd/mm/yy) : ______________________________________ 

(c) What was the doctor’s diagnosis? ________________________________________________________________ 

(d) Date of diagnosis (dd/mm/yy) : __________________________________________________________________ 

(e) Date of when the Life Assured were informed of the above diagnosis (dd/mm/yy) : _____________________ 

(f) 

State the details of all doctor(s) or hospital(s) whom the Life Assured has consulted for this condition. 

Doctor(s) or Hospital(s) & Address Date(s) consulted Purpose & details of consultation(s) 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

4. If the Life Assured was hospitalised or treated on an outpatient basis for bodily injury, please provide details: 

(a) Date of accident (dd/mm/yy) : _____________________ 

Time of accident : __________________ (am/pm) 

(b) Place of accident : _____________________________________________________________________________ 



(c) Type of accident : 

Road traffic accident Industrial accident Sports accident Cut by sharp objects or substance 

Slipped and fell Burns or scalds Hit by heavy objects or persons 

Others (please specify) _______________________________________________________________________ 

(d) Describe how the accident happened. 

_________________________________________________________________________________________________ 

(e) Describe the extent of body injuries and parts of the body injured. 

_________________________________________________________________________________________________ 

5. Nature of treatment rendered to the Life Assured: 

(a) Was surgery required for this condition? Yes No 

If yes, please state: 

Name of surgical Doctor or hospital Date of surgery 

procedure 

performing the surgery 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

(b) Types of tests or investigations done or will be done. (example ECG, CT scan, biopsy, blood test, pap smear) 

__________________________________________________________________________________________________ 

6. Any follow-up visit(s) required? Yes No 

If yes, please state date(s) of follow-up visit (dd/mm/yy) : ________________________________________________ 

7. Has the Life Assured previously suffered from or received treatment for similar or related illness prior to this 

episode? Yes No 

If yes, please provide details: 

Doctor(s) or Hospital(s) consulted Address Date(s) consulted 

_______________________________________________________________________________________________ 

_______________________________________________________________________________________________ 

8. For female Life Assured: Were you pregnant at the time of hospitalization? Yes No 

If yes, please state if there was any treatment given relating to your pregnancy during the hospitalization. 

_______________________________________________________________________________________________ 

[B] 

Other information 

1. Please provide details of regular doctors of the Life Assured. 

Doctor(s) or Address Date(s) Purpose & details 

Hospital(s) consulted of consultation(s) 

______________________________________________________________________________________________ 

______________________________________________________________________________________________ 

______________________________________________________________________________________________ 

2. Is the Life Assured claiming from any other insurance company or other sources, such as employee benefits, 

workmen compensation, Medishield and others in respect of this hospitalization or surgery or treatment? 

Yes No 



If yes, please enclose a copy of their settlement letter and provide details: 

Name of company Amount claimed (S$) Policy No. Other information 

______________________________________________________________________________________________ 

______________________________________________________________________________________________ 

[C] 

Delivery method 

I would like the claims correspondence, including cheque payment (if any), to be sent to me through the following 

method (please tick): 

mail directly to me self collect my current servicing adviser of this policy 

I authorise , , , who is my , to make the collection on my 

behalf. 

(Name) (NRIC No.) (Relationship) 

[D] 

[E] 

Declaration 

We, the Assured and Life Assured of the above named policy agree that the above statements are true, correct and 

complete and that the Company believing them to be such shall rely and act upon them. 

Consent for information on the Life Assured 

I, the Assured under the above policy, agree and authorise any medical source, insurance office, or organisation to 

release to AXA Life Insurance Singapore Pte Ltd; and AXA Life to release any medical source, or insurance office any 

relevant information concerning the Life Assured at any time, for the purpose of the assessment of this claim, I as 

the Assured fully understand that the fees (if any) payable for any reports obtained for this purpose shall be borne by 

me and give my consent to the fees being deducted from the claim if it is admitted. 

Adviser name : 

__________ 

Signature of Assured 

Contact no. : ________ __________ 

________________________________ 

Date Organisation : __________ 

________________________________________ 

Signature of Life Assured (if other than Assured 

and above aged 21) 

_________________________________________ 

Date 

[F] 

Checklist for claimant 

Please ensure that the following are in order for our processing of the claims: 

Original final bills and receipts are submitted. No photocopy or interim bills. (For claim on hospital income 

benefit or Inpatient Benefits under Prime Care plan, photocopies of the final bills are acceptable). 

Do not leave any questions on the claim forms unanswered. 

Attending Physician Statement has been completed and signed by the doctor at your own expense. 

Assured and Life Assured’s signatures are the same as in the policy record. 

For claim on spouse or children (dependents), a copy of the birth or marriage certificate is attached for proof of 

relationship. 

A copy of the identity card of the Assured and Life Assured are attached. 


Part II: Attending Physician Statement- Hospitalisation claim 

Instruction to doctor: This patient is insured with us against the happening of certain contingent events associated with his 

health. A claim has been submitted in connection with his hospitalisation. To enable us to assess the claim, please complete 

this report and return it directly to our company. For questions where date is applicable, please complete in the format of 

day/month/year. 

To be completed and signed by the Attending Physician 

I hereby certify that I personally examined the patient and my records and medical opinion are as follows: 

1. Name of patient : _____________________________________ NRIC no. : ______________________________ 

2. Are you the patient’s regular medical attendant? Yes No 

If yes, please provide details beginning with the first record in your clinic: 

Date(s) 

consulted 

Purpose & details of 

Consultation(s) 

Diagnosis 

Nature of treatment rendered, 

including type of tests and/or 

surgeries done 

If no, do you know the name and address of the patient’s regular medical attendant(s)? Yes No 


Name of medical attendant 

Address 

3. Please state the current period of hospitalization or surgery: 

Name of hospital(s) Period(s) hospitalised 

Period(s) of intensive care 

From To From To 

4. If the patient was referred to you OR if the patient had seen other doctor(s) before consulting you for this medical 

condition leading to the above hospitalization or surgery (no.3), please provide details: 

Name of Doctor(s) or 

hospital(s) 

Address of doctor(s) or hospital(s) 

Date consulted or date referred to 

you 

5. Date you were first consulted for this condition : ________________________________________________________ 

6. (a) What were the symptoms presented and the medical history as presented by the patient? 

_________________________________________________________________________________________ 

(b) When did the patient first notice or experience the symptoms? ________________________________________ 

(c) Where is the source of this information about the patient’s condition? __________________________________ 

(Patient or referring doctor or others. If others, please specify) 

(d) In your opinion, how long do you think the symptoms first appeared prior to consulting you? 

_________________________________________________________________________________________ 



7. Full description of diagnosis: 

(a) Details of primary diagnosis 

Primary diagnosis 

Diagnosis date 

Date of when patient was informed 

Underlying cause (if any) 

(b) Details of other diagnosis 

Other diagnosis 


Date of when patient was informed 

Underlying cause (if any) 

(c) Is the patient’s condition caused by an accident? Yes No 


(i) Date and place of accident, description of how the accident happened and the extent of bodily injuries. 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

(ii) Is the bodily injury consistent with the accident giving rise to the injury? Yes No 

8. Details of treatment: 

(a) Types of medication and treatment given : ______________________________________________________ 

(b) Types of diagnostic and laboratory tests done : __________________________________________________ 

(c) Was any surgery required for this condition? Yes No 


Type(s) of surgical operation(s) 

Date(s) of surgery 

(d) If more than 1 surgical procedures were performed during the same operation, were they performed through the 

same or different incisions? __________________________________________________________________ 

(e) Any likelihood of further surgery to be required? Yes No 


Type(s) of surgical operation(s) 

Tentative date of surgery 

(f) 

Patient’s response to the treatment: ______________________________________________________________ 

(g) Was the patient referred to other doctor(s) for follow up or further management? Yes No 

If yes, please state name and address of doctor and the reason(s) for referral. 

_________________________________________________________________________________________________ 

(h) Is the patient still on follow up treatment? Yes No 

If yes, please state the follow up treatment plan that the patient is currently receiving. 

_________________________________________________________________________________________________ 



9. Is the patient’s condition or surgery performed in any way related or due to: 

(a) pregnancy, infertility, sub-fertility, childbirth, birth control, sterilization, miscarriage or 

abortion? 

(b) birth defects, congenital sickness or abnormalities? 

(c) sexually transmitted disease, AIDS or HIV related illness? 

(d) self-inflicted injury? 

(e) depression, mental or nervous disorder? 

Yes No 

Yes No 

Yes No 

Yes No 

Yes No 

(f) alcoholism or drug abuse or any injury or illness suffered after taking intoxicating liquors Yes No 

or drugs? 

(g) cosmetic reasons or elective surgery? 

(h) obesity, weight reduction or weight improvement? 

Yes No 

Yes No 

(i) dental care or treatment? Yes No 

10. Regarding the patient’s medical history: 

(a) Has this patient previously suffered from the same condition prior to seeing you? 


Date of when condition was first diagnosed 

Yes No 

Name and address of doctor who made the 

first diagnosis 

(b) Has the patient been admitted to any hospital previously, either for the same or different cause? Yes No 


Name of Hospital 

Period(s) hospitalised 

Diagnosis 


From 

To 

(c) Is the patient suffering from or suffered from any other medical conditions? 


Name of doctor(s) or 

hospital(s) 

Yes No 

Address Diagnosis Diagnosis date 

11. Please enclose a copy of the diagnostic results, operation report, biopsy, histological report and all other relevant 

hospital report. 

12. Please provide us with any other additional information that will enable us to assess the patient’s claim. 

___________________________________________________________________________________________ 

__________________________ 

Date 

__________________________ 

Address and official stamp 

____________________________________ 

Name and signature of doctor 

____________________________________ 

Qualifications 


Part III: Clinical Abstract Form 

Dear sir, 

Application for a Medical Report on ________________________________ (Name) 

________________________________ 

(NRIC or birth certificate no.*) 

Purpose of the medical report 

_____FOR INSURANCE CLAIM________ 

I, the undersigned, give you the authorisation to furnish AXA Life Insurance Singapore Pte Ltd with a medical report on the 

abovenamed for the purpose stated above. 

I, confirm that a photocopy of the signed original Clinical Abstract Form is as valid and effective as the original Clinical abstract 

form. 

Below are the details of the abovenamed’s consultations at your hospital or clinic*. 

Date of admission or consultation* 

Date of discharge 

Name of doctor 

: __________________________ 

: __________________________ 

: __________________________ 

_________________________________ 

Signature of patient or patient’s parent 

or patient’s legal guardian* 

____________________________ 

Signature of Witness 

_________________________________ 

Name of patient or patient’s parent 

or patient’s legal guardian* 

____________________________ 

Name 

_________________________________ 

NRIC no. 

____________________________ 

NRIC no. 

* Please delete where applicable 

Note :- 

If the patient is below 21 years old, authorisation for the medical report is to be made by the parent or legal guardian 

of the patient. 

Please send the report directly to AXA Life Insurance Singapore Pte Ltd – Life Operations (Claims)

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