Fillable Form Gr-69232-9 Mal - Aetna Archipelago Claim Form (Page 2 of 2) in pdf

Please confirm if the payee is an Individual or Company/Entity

Individual

Complete section A and C

Company/Entity

Complete section B and C

Section A: Individual

First name

Middle name

Last name

Date of birth (dd/mmm/yyyy)

Nationality

Country of residence / location

Payee phone number

Payee email address

The relationship between yourself and the payee

Your full name

Your signature

Section B: Company/Entity

Full name

Complete address

Country of corporation

Payee phone number

Payee email address

The relationship between yourself and the payee

Your full name

Your signature

Section C

Has the payee paid the costs for the treatment that you are claiming for?

Yes

If ‘Yes’, provide evidence. (add this only if the invoices / receipts are not in that third party name)

If ‘No’, confirm the reason you have requested we pay them instead of yourself.

Yours sincerely,

Claims Team

Email:

Phone: +60-3-7724-4179

Fax:

+65-6395-6747

Aetna

is a trademark of Aetna Inc. and is protected throughout the world by trademark registrations and treaties.

Archipelago Insurance Limited does not provide care or guarantee access to health services. Not all health services are covered, and coverage is subject to

applicable laws and regulations, including economic and trade sanctions. Health information programs provide general health information and are not a

substitute for diagnosis or treatment by a health care professional. See plan documents for a complete description of benefits, exclusions, limitations and

conditions of coverage. Information is believed to be accurate as of the production date; however, it is subject to change. For more information, refer

All plans are underwritten by Archipelago Insurance Limited and administered by Aetna Global Benefits (UK) Limited, registered in England (Company

Registration No. 03554885), which is authorised and regulated by the Financial Conduct Authority (Firm Reference No. 312279). Registered at 50 Cannon

Street, London, EC4N 6JJ, United Kingdom.

Archipelago Insurance Limited is licensed by Labuan FSA, Company No. LL09355, Licence No. IS2013136. Registered office address: Unit 3A - 25, Labaun

Times Square, U0350, Jalan Merdeka, 87007 F.T. Labaun, Malaysia.

Important: This is a non-US insurance product that does not comply with the US Patient Protection and Affordable Care Act (PPACA). This product may not

qualify as minimum essential coverage (MEC), and therefore may not satisfy the requirements, if applicable to you and your dependants, of the Individual

Shared Responsibility Provision (individual mandate) of PPACA. Failure to maintain MEC can result in US tax exposure. You may wish to consult with your

legal, tax or other professional advisor for further information. This is only applicable to certain eligible US taxpayers.

GR-69232-9 MAL (6-16)

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