AIA Death Claim Form

AIA SINGAPORE
DEATH CLAIM FORM

Corporate Solutions
3 Tampines Grande, #07-00, AIA Tampines, Singapore 528799, Fax: 6538 5603 / 6538 4340, Email : sg.eb.claims@aia.com
CLAIMS PROCEDURES
Please furnish the following documents within one month from date of death of the Deceased Member :a) Duly completed Claimant's Statement (to be completed by an authorised officer of the Policyholder).
b) Duly completed Physician's Statement by the Attending Physician / Surgeon. The cost of such report will be
borne by the Policyholder.
c) Certified True Copy of Death Certificate (to be signed by an authorised officer of the Policyholder and affixed
with the company stamp).
d) Certified True Copy of the last two months payslip before the month of death (to be signed by an authorised
officer of the Policyholder and affixed with the company stamp).
e) Certified True Copy of the verdict, or findings, when an official inquiry as to the cause of death has been made.
f)
Certified True Copy of the police report if death occurs due to an accident.
g) Any other documents required, will be based on the case itself.

h) Every question must be distinctly and fully answered. The company reserves the right to pursue or obtain
further information / document should it be deemed necessary.
i)
Claims settlement (if is payable) will be made payable to the Policyholder.
Page 1 of 3
CS-CM-OCT2014
AIA SINGAPORE
DEATH CLAIM FORM
Corporate Solutions
Section 1 : Claimant's Statement

Part A : To be completed by Employer
Company Name (Policyholder) :
Policy No :
Name of Employee
Occupation
Date of Employment
Employee ID / No.
Plan Type
NRIC / Passport No.
Date of Birth (DD/MM/YY)
Sum Assured
Gender
Female
(DD/MM/YY)
Name of Dependant (if applicable)

Occupation
Relationship to Employee
Spouse
Child
Plan Type
Male
NRIC / Passport No.
Date of Birth (DD/MM/YY)
Sum Assured
Gender
Female
Male
Part B : Details of Death

1.
Date of Death (DD/MM/YY)
2. Place of Death
3.
Cause of Death
4.
When did the deceased first complain of or give other indication of his last illness?
Date (DD/MM/YY)
5.
When did the deceased first consult a physician for his last illness?
Date (DD/MM/YY)
6.
Was the deceased in the full time employment (i.e. on the payroll) of the policyholder at the time of death?
7.
If yes, please let us have his / her last full month drawn salary
7.
If no, when was his / her employment terminated?
Date (DD/MM/YY)
8.
When was the last day he / she were actively at work?
Date (DD/MM/YY)
9.
Was an inquest or post mortem examination held on the body? If yes, please furnish certified copy of the
verdict or findings.
10.
Name and address of all physicians who attended deceased during his last illness and during three years prior thereto:Name of Physician
11.
Address
Yes
No
Yes
No
Date of Attendance
Disease or Condition
Policies Dated
Amounts of Assurance
With what other companies, and for what amounts, was the life of deceased assured?
Companies
Part C : Declaration and Authorisation by Employer

This undersigned hereby makes claim to said assurance in AIA Singapore Private Limited (AIA)(the Company or AIA Singapore) and agree
that the written statements and affidavits of all the physicians who attended or treated the Assured and all other papers called for by the
instructions hereon, shall constitute and they are hereby made a part of these Proofs of Death, and further agrees that the furnishing of this
form, or of any other forms supplemental thereof, by said Company shall not constitute nor be considered an admission by it that there was any
assurance in force on the life in question, nor a waiver of any of its rights or defenses.
I/We consent to AIA Singapore, its associated persons/organisations, third party service providers and representatives, whether within or
outside Singapore (collectively AIA Persons) to collect, use, disclose, store, retain and/or process (collectively, Use) all personal data and
information (Personal Data) provided to AIA Persons or that they possess about me/us, in the manner and for the purposes described in the
AIA Personal Data Policy (PD Policy) which is available on AIA Singapores website.
I/We agree to accept the provisions in the PD Policy as amended from time to time. Where Personal Data of another person is disclosed by
me/us, I/we confirm that I/we have obtained the consent of the individual concerned, except to the extent such consent is not required under
relevant laws to collect, use and/or disclose such Personal Data. I/We waive (on my/our own behalf and on behalf of each such other person)
any right to claim against any of the AIA Persons for any Use in the nature of or for the purposes described above or in the PD Policy. I/We will
indemnify AIA Persons for all losses and damages if I/we breach these provisions.
This consent shall bind my/our successors and assignees, and remains valid, notwithstanding death, irrespective of whether or not our
Application/form is accepted by AIA Singapore. A photocopy of this consent shall be valid and effective as the original.
Signature of Employer
Page 2 of 3
Company's Name & Stamp
*G5010000*
*G5010000*
Date (DD/MM/YY)
CS-CM-OCT2014
AIA SINGAPORE
DEATH CLAIM FORM
Corporate Solutions
Section 2 : Physician's Statement

To be completed by Attending Physician
(The medical report fee, if any, will be borne by the Claimant)
Company Name (Policyholder) :
Policy No :
Name of Deceased
Occupation
NRIC / Passport No.
1)
Date of Death
2)
Place at time of death
3)
What was the immediate Cause of Death?
4)
How long has the illness existed prior to Death?
5)
Did Deceased have any symptoms prior to Death? Yes No
6)
When did Deceased first consult you for this condition?
If Yes, Date symptoms first started :
Date :
Nature of Symptoms :
When did Deceased last consult you for this condition?

Date :
7)
When was the diagnosis leading to the cause of Death first

diagnosed?
Date :
9)
8)
Was Deceased informed of the diagnosis? Yes
No
If Yes, when was the Deceased first told? :
Did Deceased suffer from any other illness?

Illness
Period Of Illness
Date of Diagnosis
Date & Type of Treatment
10) Was the Death in any way partly attributed to Deceased's habits, family history, occupation OR previous diseases? Yes
No
If Yes, give details :
11) Was there any predisposing caused of the deceased's death in his / her habits (use of alcohol, narcotics, etc) family history, occupation or
previous sickness?
12) Name and address of all physicians who previously consulted by Deceased for the above condition.
Name of Physician
Name & Address of Clinic
Date of Attendance
I hereby declare that I was physician in attendance during the last illness of the deceased and that the foregoing answers are true to the best of
my knowledge and belief and that no material fact has been concealed from the Company.
Page 3 of 3
Signature of Physician / Surgeon
Date (DD/MM/YY)
Name / Designation
Name and Address of Clinic / Hospital & Stamp
CS-CM-OCT2014

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AIA SINGAPORE

DEATH CLAIM FORM

g) Any other documents required, will be based on the case itself.

Claims settlement (if is payable) will be made payable to the Policyholder.

Section 1 : Claimant's Statement

NRIC / Passport No.

Date of Birth (DD/MM/YY)

Name of Dependant (if applicable)

NRIC / Passport No.

Date of Birth (DD/MM/YY)

Part B : Details of Death

Date of Death (DD/MM/YY)

If no, when was his / her employment terminated?

When was the last day he / she were actively at work?

Part C : Declaration and Authorisation by Employer

Company's Name & Stamp

Section 2 : Physician's Statement

(The medical report fee, if any, will be borne by the Claimant)

Company Name (Policyholder) :

NRIC / Passport No.

Place at time of death

What was the immediate Cause of Death?

How long has the illness existed prior to Death?

Did Deceased have any symptoms prior to Death? Yes No

When did Deceased first consult you for this condition?

If Yes, Date symptoms first started :

When did Deceased last consult you for this condition?

When was the diagnosis leading to the cause of Death first

Was Deceased informed of the diagnosis? Yes

If Yes, when was the Deceased first told? :

Did Deceased suffer from any other illness?

Date & Type of Treatment

If Yes, give details :

Name & Address of Clinic

Signature of Physician / Surgeon

Name and Address of Clinic / Hospital & Stamp

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