Death claim form - AXA Life Insurance Singapore

Death claim form
1. Notice Of Claim
Written notice of claim must be given to AXA Life within 90 days after the death of the Life Assured.
2. Claim Documents
The claimant shall, at his own expense, furnish the original death certificate of the Life Assured, original proof of
entitlement^ and medical reports to AXA Life, together with a fully completed claim form (refer to point 3 Claim form).
(^ Marriage certificate, birth certificate, Will, Grant of Probate / Letters of Administration)
If the death is due to an accidental or unnatural cause, in addition to the above, the claimant shall, at his own
expense, furnish the original post mortem and toxicology reports, coroner’s report, copy of police investigation report
(if available) and newspaper cutting (if available). If the death occurs outside Singapore, the claimant shall furnish
additional documents such as the repatriation of body certificate, burial or body cremation certificate (if available).
The death certificate and all supporting documents not written in English must be translated to English and
authenticated by the Singapore Embassy.
Please submit a copy of the claimant’s NRIC and a copy of the Life Assured’s NRIC or birth certificate and the
original policy contract*. (*Not required for waiver of premium claim)
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 claimant. Please ensure that it is fully completed, signed, dated and
witnessed.
3.2 Part II Attending Physician Statement for Death claim
This is a separate document. Please obtain the Attending Physician Statement that is relevant for a death
claim. 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 claimant.
3.3 Part III Clinical Abstract Application form (Page 5)
To be completed and signed by the Life Assured’s next-of-kin.
For death occurs outside Singapore, in addition to the claim form, the following forms must be submitted:
3.4 Death Abroad Questionaire and Declaration of Identity Form
4. Submission of Claim Form
You can submit the duly completed claim form and the claim documents 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
Death claim form / Mar 11 Page 1 of 5

Part I: Claimant’s statement - Death Claim Form
Type of benefits you are claiming:
Death (basic/term) ADB / ADD / AI / PA Waiver of premium/PB Others (please specify): _________________
Policy No. : (1) ___________________________ (2) __________________________ (3) ________________________
Assured’s Details:
Name : __________________________________ NRIC no. : __________________ Contact no. :_______________________
Last Address prior to death : _______________________________________________________________________________
Life Assured’s Details (if other than Assured):
Name : __________________________________
NRIC no.: ___________________ Relationship with Assured : __________
This claim is submitted to AXA Life through : self current servicing adviser
[A]
Details of death of Life Assured
1. Date of death (dd/mm/yy): _____________________ Place of death: ____________________________________
2. Cause of death: _________________________________________________________________________________
3. Proof of death:
(a) Was a post-mortem or autopsy carried out? Yes No
(b) Was any coroner’s inquest held? Yes No
4. Did the Life Assured leave a Will? Yes No
If yes, please submit a copy of the last WILL.
5. Did the Life Assured leave behind any spouse and/or children? Yes No
If yes, please provide the details of the surviving spouse and children:
(a) Name and age of spouse: ________________________________________________________________________
(b) Number of children, name and their respective ages: ______________________________________________
_________________________________________________________________________________________________
If no, please provide the details of the surviving parents and siblings, if available:
(a) Name and age of parents: _______________________________________________________________________
(b) Number of siblings, name and their respective ages: _______________________________________________
__________________________________________________________________________________________________
6. (a) Life Assured’s last occupation prior to his death: _____________________________________________________
(b) Name and Address of Life Assured’s last employer: __________________________________________________
__________________________________________________________________________________________________
7. (a) Describe fully the symptoms for which the Life Assured first consulted a doctor.
__________________________________________________________________________________________________
(b) Date of which the symptom(s) first occurred (dd/mm/yy) : __________________________________________
(c) Date when the Life Assured first consulted a doctor (dd/mm/yy) : ______________________________________
(d) What was the doctor’s diagnosis? _________________________________________________________________
(e) Date of diagnosis (dd/mm/yy) : __________________________________________________________________
Death claim form / Mar 11 Page 2 of 5

Part I: Claimant’s statement - Death Claim Form
(f)
State the details of all doctor(s) or hospital(s) whom the Life Assured has consulted for his last illness, including
the doctor who last attended to him prior to his death.
Doctor(s) or Hospital(s) & Address Date(s) consulted Details of consultation(s)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
8. Was the cause of death due to an accident? Yes No
If yes, please provide the 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
Burns or scalds Slipped and fell
Others (please specify) ________________________________
(d) Describe how the accident happened.
_________________________________________________________________________________________________
(e) Describe the extent of body injuries and parts of the body injured.
_________________________________________________________________________________________________
(f) Was the accident reported to the police? Yes No
If yes, please provide a copy of the investigation report and the contact details of the police officer-in-charge.
__________________________________________________________________________________________________
(g) Was there any witness to the accident? Yes No
If yes, please provide names and addresses of the witnesses.
______________________________________________________________________________________________
9. Has the Life Assured previously suffered from or received treatment for similar or related illness? Yes No
[B]
If yes, please provide details:
Doctor(s) or Hospital(s) consulted Address Date(s) consulted
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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. Does the Life Assured have other insurance policies with other insurance companies? Yes No
If yes, please provide details:
Policy number Name of company Commencement date Pan Sum Assured
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Death claim form / Mar 11 Page 3 of 5

Part I: Claimant’s statement - Death Claim Form
[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 collection on my behalf.
(Name) (NRIC No.) (Relationship)
[D]
[E]
Declaration
I, declare that the statements and answers given above are true and complete to the best of my knowledge and belief
and that I have not made any false or fraudulent statement, any suppression and concealment of facts.
Consent for information on the Life Assured
I 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 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.
DATED this _______________ (day) of ________________ (month) __________________ (year).
Signature of claimant
Name : _________________________________
NRIC/Passport no. : ______________________
Address: ________________________________
________________________________________
Contact no. : _____________________________
Relationship to the deceased _______________
________________________________________
Signature of witness
Name : __________________________________
NRIC/Passport no. : ________________________
[F]
Checklist for claimant
Please ensure that the following are in order for our processing of the claims:
Original or certified true copy of death certificate and proof of entitlement are submitted. Certification can be
done at our AXA Life Customer Service Centre or by a law firm.
Do not leave any questions on the claim forms unanswered and the forms are fully completed, signed, dated and
witnessed.
A copy of the identity card of the claimant is attached.
Death claim form / Mar 11 Page 4 of 5

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)
Death claim form / Mar 11 Page 5 of 5