AXA _______________________

<Address>
<Address>
<Customer Service Centre>

______________
@ ______________
 www.axa.________
Co. Reg No. _____________

Personal Accident Claim Form Policy/ Certificate No.

To expedite your claim, please (1) complete this form, (2) prepare the relevant documents required in Page Two and (3) submit them to AXA
Office as soon as possible. Thank you.

A. POLICY DETAILS
Policyholder/Insured’s
Full Name
Office/Mobile No. Email

Correspondence
Address
GST-registration No. Date of
(If registered) registration

B. CLAIMANT DETAILS (if other than above)

Full Name

Mobile No. Relationship

C. ACCIDENT & INJURY DETAILS

Date and Time Date : Location

of Accident Time : of Accident

Medical Expenses □ Total Permanent
Others (Please specify)

Type of loss/claim □ Temporary Partial Disablement
Disablement

Temporary Total Disablement
Accidental Death

Description
of Accident

Description of Injury Have you injured the

Sustained same part before?
(e.g. body part
injured, injury type) □ Yes □ No
Date on which you resumed duty?
Have you made a Name of other party / insurance company :
claim against any
Description of claim :
other party in respect
of this event? If yes,
please provide details

D. BANK
BANK ACCOUNT DETAILS
Please provide your bank details for us to accelerate your claims payment process by direct transfer to your bank account.
Name
Bank Name
(as per bank account)
Account No. Bank Branch
Note:
Note Claim payment via Direct Credit is within 3 working days whereas cheque will be processed within 14 working days subject to
receipt of all documentations required.
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E. DECLARATION & CUSTOMER’S DATA PRIVACY NOTICE

[Declaration] I/We hereby declare that the above statements and facts are true, copies of documents are identical with the original one, and that I/We
have not withheld from the Company, any information within my/our knowledge connected with the accident.
[Customer’s Data Privacy Notice] AXA Affin General Insurance Berhad is committed to protect the personal data submitted by and collected from you.
For further details, please refer to our “Data Privacy Notice” published in our website.

_____________________ _________________________________________________________
Date Signature of Insured / Claimant

F. DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT

Below is a list of minimum documentation required to process your claim. In certain circumstances, additional information may be
required in order for further confirmation.

Documents Required
(Please tick against the documents you have submitted)

Medical Certificates

Original Hospital/ Medical Bills & Receipts

Medical Reports

Inpatient Discharge Summary – for hospital income benefit claim only

Police Report/ Accident Report – for motor accident injury claim or criminal incident

Employment Letter & 3-month salary slips (for Group PA on un-named basis only)

For Fatal Accident – in addition to above:

above:

Certified True Copy (CTC) of Death Certificate / Post-Mortem Report / Burial Certificate

CTC of Deceased’s NRIC / Employment Letter & 3-month salary slips (for Group PA only)

CTC of Letter of Administration / Distribution Order (only if un-named beneficiary for individual policy)

G. TRACK YOUR CLAIM STATUS

Once your claim is registered, you will be updated through email. If you have any enquiries on your claim, please reach us at:

AXA is committed to making your personal accident insurance claim process as easy as possible.
Thank you for insuring with us. We are always glad to be of your service.

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 Medical Report
 Private & Confidential
This form is to be completed by the Patient’s Attending Doctor.
The cost of this medical report is to be borne by the Claimant.
 
Date of Accident
1. Full Name of Patient (= Claimant)
(DD MM YY)

2. Cause of Injury

Final Diagnosis Part of Body (State Left/Right limb) Symptoms

Nature and Extent of the Injury

3.
Describe complications, if any

Date You First Consulted Admitted Discharged

Date of Hospitalization,
For This Injury/Condition
if applicable (DD MM YY)
(DD MM YY)

Treatment(s) Completed Ongoing Other Treatments, if any Completed Ongoing

4.
 X-ray    

 Surgery    

 Special Diagnostics    

How long has the Patient been disable Totally From: To:
from engaging in or attending to usual
5.
employment or occupation as a result
of these injuries? Partially From: To:

Any Sign of Pre-Existing Injury? Date Treated

Estimated MM/ YY
6-1.
If yes, please provide details
(Nature & Cause of Injury/ Symptom)

Do you think current accident

aggravated injury?
6-2.
If yes, please provide reasons
for your opinion

At the time of accident, was the patient

7. suffering from any illness?
If yes, please provide details

Details of any circumstances which

may have contributed to the accident
and/or lengthen the period of
8.
disability.
(e.g. physical impairments, medical
history or intoxication)

Any other information or professional

9. advice that should be made known to
AXA?

  I hereby certify that the above-named met with accident referred to, and that the foregoing statements are correct.
 
 
 
 
Signature

Name of Treating Doctor/ Specialist Date

Official Stamp of Hospital/ Clinic