Doctor’s certificate form for Hospital Surgical & Hospital Cash benefit.
Copy of Identity card from the insured and the policy holder
Letter of attorney (if needed)
Original stamped receipt and billing details from the hospital or medical personnel.
Results of examination/laboratory or diagnostic.
Results of anatomy pathology (if there’s a surgery).
A copy of the doctor’s prescription related with the treatment.
Doctor’s letter of recommendation for diagnostic examination and laboratory before/after the hospitalization, implant and/or prosthesis, physiotherapy, dyalisis and cancer treatment.
To be completed by the Insured.
To be completed by the attending doctor.
To speed up the process - Send the claim form and the doctor’s certificate through email firstname.lastname@example.org earlier.
To Complete the Claim - Send all the physical evidence of the claim form, doctor’s certificate, and others supported documents to:
Individual Claim Department FWD Life, World Trade Center 1, 11th Floor, Jendral Sudirman Street Kav. 29-31 Jakarta 12920
Please submit the completed claim form with required supporting documents to us within 30 days after the time the proof is required.
PT FWD Life Indonesia ("FWD Life") is registerd and supervised by the Financial Services Authority.