Paley Number Health Claim Reimbursement Form ‘This orm et be filled out bythe claimant ond policy owner. the claimants under 8 years od, the paentguordin should accomplish tin Behalf fhe minor. ‘This request for reimbursement s subject to validation and approval. If approved, the claims payout will be credited to the account 1e Policy Owner. Please ensure that al signatures tally with the signatures that were provided to AXA, 1. Details of the Claimant (all fields are mandatory) Fullname of Policy Owner (LAST NAME, FIRST NAME, MIDDLE NAME): Mobile number of Policy Owner Emailadéress of Policy Owner FullName of insured Claimant No.1 (LAST NAME, FIRST NAME, MIDDLE NAME}: Mabie number of inured cla Email adresrof Insured Claimant no. lalmant No.2 (LAST NAME, FIRST NAME, NAME}: Mobile numberof clamainne. 2 mail address of nsured Calmantne.2 FullName of sured Claimant No.3 (LAST NAME, FIRST NAME, MIDDLE NAME}: Mobile number eftnsured claimant no. 3 mail address of nsured Claimantne. FullName of insured claimant No.4 (LAST NAME, FIRST NAME, MIDDLE NAME): Mobile numberof Insured claimant no. 4 mail address of insured Claimant ne. 2. Claim Type (you may tick off as many as the number of claims you are submitting) Over-the-counter (OTC) vitamins (GHA only) (Forcooh benefit submit SO) QO health screening O Inpatient Benefit O Maternity Benefit (GHA only) Ocashsenet(chsony) ©) Preand Post Hospitalization Benefit Dental/optical © ourpatient consultation ) Emergency Benefit re spo bron Lots,Heath Cain Reimbursement orm Application Number, Cor A. If Health Screening Please indicate Executive Check-Up (ECU) package availed or list down tests done for ECU (attach official receipts) Hospital/Clinie + Location Date of Health Screening Initial Diagnosis Date(s) of Confinement Final Diagnosis Date patient first became aware of any signs ‘or symptoms for this condition ‘Treating Doctor! ‘Surgical Procedure done C. If Outpatient Consultation or Treatment (Includes Emergency Room Availment) Initia Diagnosis Date patient first became aware of any signs or symptoms for this condition otsHeath cain Reimbursement orm Application Number, Final Diagnosis Date(s) of Consultation/Treatment Includes Emergency Room Availment/ Pre and Post Hospitalization Av ‘Type of treatment or medicine received Treating Doctor!s (Please attach Doctor's ordersrescrptions and Oficial receipts) D. If Emergency Room treatment due to Acci Nature of ncident/Cause (NOI): Date of incident: Place of Incident: Diagnosis to include injury details and Official receipts needed, you may use the back sheet. 4. Breakdown of Claim Please fil out this portion ifthe claim is for multiple Insureds (under family plan) and/or multiple benefits. If more space is Type of Claim Name of Insured Receipt Details SUM: Bots.Heath Claim Reimbursement orm Application Number, 5. Supporting Document Submitted with this form Please tck against the documents you have submitted together with this relmbursement form. We will notify you or your Financlal ‘Executve/Financial Advsor/Brokerifwe need to obtain aéitionalinfarmation from you or from ether parties to assess your claims © completed original Reimbursement Form Q origina final terized medical bils, proof of payment, eceots Admising and discharge history applicable), doctor’: prescriptions © Dalit 19 ofthe Policy Owner -submit photocopy(es) iileatone grrimesitnd Duiheneet ith cpm ane at O Pokey ouners prot ofbankscnunt {yaa hov any aestneig tm or athe ape of he ore pei cnet uA et liner tine 8:80 a 11400-1888 4222 (A). Clens must be subrted along mith allsupporing docuests with 30 das fom dat of weetment. Send ths cla form agedhe th ‘supporting document to any AYA Service Center most ccessbet9 you eee © Fumo raansten topcable fr these and Baia poices) Pleas out Dire ret to count Section and submit pros Sank account onnerhin. Femnder Rune varie an alowe tte bank accor e oly Onna, REQUEST FOR DIRECT CREDIT To BANK ACCOUNT. account type: sank name ‘Account Number of Paley Owner: [Oreo account [Owevobak Ooner. ranch ame: Swit cede (erNonMetrabank) Account Name of Paley Owner: indy attach on this bx the oly owner’ proot of acount which can bein the frm ofthe allowing: pest slip or screenshot ofthe bank acount number (include the names ef thepalicy ewer andeline bank. The acaunt number snd name should mateh he deta provided shove for validation purpose ‘ly puta check te rare ayo hve competed he neces requrarenon ths er Ihave ached the pyee rot ef acount wich how te deposi rset othe bank account nde wih te payee anecdote ane et ‘ebankusngoninesaneng Declarations and Agreements: 4 declare that the proceeds ofthis sppition/pacy once deposits tthe account aforementioned shallbe equalentto payment me directly efthe sare andl shall render AXA Pippines, ts sucessrsn- interests andasins,inclingits decors, fcr, employees and agents Fee ane harmless {fom ny further lim, demand oracton whatsoever, which in oF equtyLeverhag, new hve, or whieh! my sucassrs and asigns hereaker may have under this said appiationpaley 2. lunderstand that shoul the proceeds be credited toa non tevbank account, coresponding es shall be charged to my account. 4. Thereby declare thatthe ceposit spor screenshot a onine bank Ihave attached on he pref ef account ection validates orectnfrmation regaring my ans acount 4 The undersigned, so kell esponsibility the acuray ofthe aecount nae and number indeated above. Shou here be any eras in the Infermaton, {understand that thi wl esl delays nthe crediting ofthe policy proceeds and! shall bear the concequences, 5. Tunderstand thatthe information| provided wil be validated and axthentcatedby AXA Pilppnes. Signature over printed ame of plc owner Date of signing mmddyy) otsHeath cain Reimbursement orm Application Number 1. Beforesgnngthis Clim Form, teecare that have earful rae, understood, and agree with all thenstuctons ané questions that are wten further Lingerstang, declare and areethatall statements ang answers made in thir lim Form, andaldocumentestached, rt the bert my knoniegge ane belie complete anu, corey recorded, and shal orm part of andbe the bss cam atessmentané approval lhe inlormaton| provided an ‘his appleton frm are thebestof my krowiedge rue and eared 2 fay of my personal information collected or helé by AXAPhilppines whether containedinthe applications or ethers], maybe ved stored, disclosed, ‘eanfere whether within or outside the Pisppines) to seh persons as AXA Philippines may consider necessry,ineusng without miation But not lied any ots fiiated relate companies, ray indviduasfrganizaions/corporationsentiies associated with AKA Philppnes ‘toprocess and deal wth my aims request, to promgeall seraces related to said request ane {to communicate with me eranypurpeseancor to comply with the laws of any appicabejuristion 2 understand that have the righ to access aur pessoal nfrmation a any Une: corect a ety any infxmation calle or held by AXAPhilaines lihich aremaccurate, false, orincomplete object ica of any unauthorized coletion, acer bockinformation whichis complete outdated fle, and such ether rights 35 may be available uncer the Data Privacy Ac. | understand that such request may be mace in wring and submit to AKA hippies 4 understand that tices relate to my claim maybe sent te me through al mall or SMSin the addess/number provided above Sinatace over printed name Date of signing (mmddyy) 8. Consent for Distributor to access information In elation tthe claims request af which fam the paiey une, understand ane are provide relevant poi information suchas bu net ited my name, des, date of bith, place of bith, contaet pumberinformation, ema ade, insureds paley number, aim proceeds, et relative said alte rryetserburr forthe purpose of hime processing understand thatthe enumerated ple information wiilenly be use by my dstibutr forthe above purpase an shall be kept byhimher unt our transaction has been completed and in accordance with AIA PiippinesPersenal ata Reteon Policy Signature ve printed name of paley owner 9. Assisting Distributor Declarations dete 3 have ly explained toe Ptzy Own al eleart irmation egg he warsacos in thi form an 2) he cont dts in We orm not conta! number a ers cedes. so cry that) persona saw ha Poly One evacable beneiais & assigns ayaa hay tel signatures ts erm andhave verte h/her/tra erty and 2 nave examned te oi! D/s provided and the ahd photocopy are we end cove capes of te orgs Name of Distbutor Stenature of Ditiutor oie, Bots