Claim Status Detail Form

Claim Submission

Describe the circumstances of the incident

Policy Number

Please enter a valid policy number.

Number of your Travel insurance policy

Policy Number

Please enter a valid policy number.

Number of your Motor insurance policy

Policy Number

Please enter a valid policy number.

Number of your Home Insurance Policy

Policy Number

Please enter a valid policy number.

Number of your Personal Accident policy

Date Of Loss

Please enter a date of loss

When did the incident occur

Date Of Loss

Please enter a date of loss

When did the incident occur

Date Of Loss

Please enter a date of loss.

When did the incident occur

Date Of Loss

Please enter a date of loss.

When did the incident occur

Nature of Loss

Please choose a valid nature of loss.

Nature of Loss

Please choose a valid nature of loss.

Nature of Loss

Please choose a valid nature of loss.

Nature of Loss

Please choose a valid nature of loss.

Nature of your Claim

Please choose a valid nature of your claim.

Nature of your Claim

Please choose a valid nature of your claim.

Nature of your Claim

Please choose a valid nature of your claim.

Nature of your Claim

Please choose a valid nature of your claim.

Brief Summary of the accident

Enter valid summary

Brief Summary of the accident

Enter valid summary

Brief Summary of the accident

Enter valid summary

Brief Summary of the accident

Enter valid summary

Policy Number

Please enter a valid policy number.

Policy Number

Please enter a valid policy number.

Policy Number

Please enter a valid policy number.

Policy Number

Please enter a valid policy number.

How long did you have the symptoms before you consulted a doctor?

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How long did you have the symptoms before you consulted a doctor?

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How long did you have the symptoms before you consulted a doctor?

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How long did you have the symptoms before you consulted a doctor?

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Please provide details of the symptoms you experienced that led to you visiting a doctor

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Please provide details of the symptoms you experienced that led to you visiting a doctor

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Please provide details of the symptoms you experienced that led to you visiting a doctor

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Please provide details of the symptoms you experienced that led to you visiting a doctor

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Date you first consulted a doctor for this condition (dd/mm/yyyy)

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Date you first consulted a doctor for this condition (dd/mm/yyyy)

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Date you first consulted a doctor for this condition (dd/mm/yyyy)

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Date you first consulted a doctor for this condition (dd/mm/yyyy)

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Please provide the name and address of the doctor whom you had first consulted for this illness

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Please provide the name and address of the doctor whom you had first consulted for this illness

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Please provide the name and address of the doctor whom you had first consulted for this illness

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Please provide the name and address of the doctor whom you had first consulted for this illness

Field is required

Date of diagnosis (dd/mm/yyyy)

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Date of diagnosis (dd/mm/yyyy)

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Date of diagnosis (dd/mm/yyyy)

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Date of diagnosis (dd/mm/yyyy)

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Name and address of the doctor who confirmed the illness/ diagnosis

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Name and address of the doctor who confirmed the illness/ diagnosis

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Name and address of the doctor who confirmed the illness/ diagnosis

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Name and address of the doctor who confirmed the illness/ diagnosis

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Details of diagnosis

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Details of diagnosis

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Details of diagnosis

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Details of diagnosis

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Have you previously experienced or are you being treated for any similar or related illness?

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Have you previously experienced or are you being treated for any similar or related illness?

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Have you previously experienced or are you being treated for any similar or related illness?

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Have you previously experienced or are you being treated for any similar or related illness?

Field is required

Details of any other doctor(s) consulted for this illness & date of the consultation

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Details of any other doctor(s) consulted for this illness & date of the consultation

Field is required

Details of any other doctor(s) consulted for this illness & date of the consultation

Field is required

Details of any other doctor(s) consulted for this illness & date of the consultation

Field is required

Please upload any document or image that can help us to understand the circumstances leading to loss.

Driving License

Please upload a copy of your driving license

STNK

Please upload a copy of your vehicle STNK

KTP

Please upload a copy of your KTP

Damage Photographs

Please upload all damage photographs (max 6)

KTP

Please upload a copy of your KTP

Boarding Pass/Flight Tickets

Please upload a copy of your flight tickets/boarding pass

Medical Bills/Reports to be reimbursed

Please upload a copy of verified bills to be reimbursed

KTP

Please upload a copy of your KTP

Medical Bills/Reports to be reimbursed

Please upload a copy of verified bills to be reimbursed

KTP

Please upload a copy of your KTP

Damage Photographs

Please upload all damage photographs (max 6)

Upload section for each document required (depending on the selected illness)

Please upload all damage photographs (max 6)

Upload section for each document required (depending on the selected illness)

Please upload all damage photographs (max 6)

Upload section for each document required (depending on the selected illness)

Please upload all damage photographs (max 6)

Upload section for each document required (depending on the selected illness)

Please upload all damage photographs (max 6)

Maximum 2 MB. PDF, PNG or JPG files only.

Contact Information

First Name

Enter Your Name

Middle Name

Enter Middle Name

Last Name

Enter Last Name

Email Address

Enter Valid Email

Enter Phone Number

+62

Enter Valid Mobile Number

Alternative Phone Number (Optional)

+62

Enter Valid Mobile Number

Region

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City

Select City

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