Please fill out the form along with the required documents for claim review
Declaration, Authorization & Customer's Data Privacy Consent
[Declaration] I/We hereby declare that the below 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.
[Authorization] I/We hereby authorize any hospital physician or other person who has attended or examined to the Insured, to furnish PT. AXA Insurance Indonesia or its authorized any representative, and all information with respect to any illness or injury, medical history, consultation, prescription or treatment, and copies of all hospital or medical record. A copy of this authorization shall be considered as effective and valid as the original.
[Customer's Data Privacy Consent] I/We hereby authorize PT. AXA Insurance Indonesia to use my/our personal data and information (such as name, address, phone number, etc.) as stated in this form or in other means, including other parties which have an agreement relationship with PT. AXA Insurance Indonesia and/or its affiliates, in relation to any activities related to the policy issued under this form.
Declaration & Authorization
I/ We hereby agree to authorize PT. AXA Insurance Indonesia to use, utilize and inform personal data / personal information to other parties who cooperate with AXA in relation to the implementation of commercial programs to improve features, facilities and / or services to me.
I/ We hereby allow PT. AXA Insurance Indonesia to inform me about products, programs and other activities in connection with the enhancement of AXA features, facilities and / or services to data owners through written media (electronic or non-electronic)