OUTPATIENT MEDICAL INSURANCE CLAIM FORM RETAIL CORPORATE Note The insured

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                                                         OUTPATIENT MEDICAL INSURANCE CLAIM FORM (RETAIL / CORPORATE)

Note :The insured member is required to complete the following claim form and attach all the original medical bills when filing the claim.


SECTION A: TO BE COMPLETED BY INSURED MEMBER
 1) Name of Insured Member                                        NRIC / Passport No.             Occupation               Marital           Date of Birth          Sex      3) Present Home Address
                                                                                                                           Status


 2) Name of Patient (if other than the Insured Member)            NRIC / Passport No.             Occupation               Marital           Date of Birth          Sex      4) Contact No. & Email Address
                                                                                                                           Status




 5) Sickness / Accident: Nature of Illness/Final Diagnosis. If it is due to Accident, please describe nature of injury
                                                                                                                                6) SETTLEMENT OPTION. Please tick your preferred settlement mode. Kindly note
                                                                                                                                that the payee refers to the Policyholder or Insured Member only.
                                          Conditions                                                 Date First Treated
                                                                                                                                (a) FOR PAYMENT DRAWN IN SINGAPORE ONLY
 (a)
                                                                                                                                (    ) Cheque Payment. Please furnish name of payee:
 (b)
                                                                                                                                ___________________________________________________________________
 (c)
                                                                                                                                (b) FOR PAYMENT DRAWN OUTSIDE SINGAPORE
 (d)
                                                                                                                                (    ) Demand Draft. Please furnish name of payee:
 (e)
                                                                                                                                ___________________________________________________________________
 (f)
                                                                                                                                (    ) Telegraphic Fund Transfer. Kindly note that this settlement option is only
 (g)                                                                                                                                   available if the payment is more than S$1000/-. Please furnish bank details:

                                                                                                                                Name of Account Holder: ______________________________________________
 I hereby authorise any hospital, physician, person or organisation to disclose when requested to do so by AVIVA                Name of Beneficiary Bank & Branch: _____________________________________
 LIMITED, and all information with respect to any illness, injury, medical history, consultations, prescriptions or
 treatment, and copies of all hospital or medical records. A photostat copy of this authorisation shall be considered           Address of Beneficiary Bank / Branch: ____________________________________
 as effective and valid as the original.
                                                                                                                                ___________________________________________________________________
 I certify that the above statements and answers are true and complete to the best of my knowledge and belief.
                                                                                                                                ___________________________________________________________________

                                                                                                                                Beneficiary Bank Account No.: __________________________________________

 Signature of                                          Signature of                                                             SWIF Address / Clearing Code (if applicable): ______________________________
 Insured Member : ______________________               Patient : ______________________          Date: _______________
                                                                                                                                NOTE: (i) Payment shall not include clinic, physician & any other medical providers.
                                                                                                                                      (ii) If CPF Medisave is used, the appropriate amount would be credited to the
                                                                                                                                           respective CPF Medisave account.
SECTION B: TO BE COMPLETED BY ATTENDING PHYSICIAN / SURGEON

Note : If there are multiple doctors, this Section is to be completed by the last attending physician.


Name of Patient :                                                                                              NRIC / Passport No. :


1) Final Diagnosis :                                                                                           ICD Code :


                                                                                                               DRG Code :



2) Other Diagnosis :                                                                                           ICD Code :


                                                                                                               DRG Code :



3) Nature of Treatment :                                                                                       4) Date of Treatment rendered :




4) Doctors previously consulted by the patient for the above condition.

   Name                                                    Approximate Date                   Name of Clinic                                     Address




  Signature of Physician / Surgeon            :

  Name of Physician / Surgeon                 :

  Name and Address of Clinic / Hospital       :




  Date                                        :