Form Gr-69232-9 Mal - Aetna Archipelago Claim Form

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Archipelago Insurance Limited
Unit 3A-25
Labuan Times Square
U0350, Jalan Merdeka
87007, F.T. Labuan
Date Created
Name of person who sent the claim
Address line
Postal Town
Postal County/State
Postal code
Email address
add the name of the person who sent the claim to us.
Title Name Surname
Claimant name:
ID number
Claimant’s member ID:
Title Name Surname
Planholder name:
Plan number
Plan number:
add total claimed amount in invoice currency.
We have received your claim for the amount of
You have requested that we pay any eligible costs for this claim into the following account:
Title Name Surname
Payee name:
Bank Account number
Account number:
Bank and branch name
Bank and Branch name:
Including IBAN, BIC, Swift, Sort, etc.
Bank code:
We notice that the payee name is different to your name or the name of any adult dependent on your
policy. Please fill in the payee details on the next page and send it back to us at the address above or you
(insert relevant email ID),
can email a scanned copy to us at
along with the requested additional documentation if applicable, so that we can review your request. This
does not guarantee that we will be able to make payments to your nominated payee.
We also need to make you aware that if the payment to the payee is approved by us and such payment is
made, the payee will receive a Claims statement containing information which may allude to the symptoms
or medical condition for which the treatment costs were incurred.
GR-69232-9 MAL (6-16)
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