SUPPORTING DOCUMENT(S) CHECKLIST

Please keep the original receipt(s) and other claim documentation for 6 months from the claim completion date. AXA reserves the right to request additional information/documentation to support each claim.

Basic documents:

1. Hospitalisation Claim Form I and Disability/Accident/Hospitalisation Claim Form II
2. Original hospital receipt(s) and itemized hospital bills
3. Original medical expenses receipt(s)
4. Copy of ID or passport of the Insured/Policy Owner (if not provided before)
5. Copy of Laboratory/X-ray/CT Scan/MRI/Pathology report(s)
6. Copy of sick leave certificate
7. Copy of Hong Kong public hospital discharge summary (no need to submit Claim Form II in this case)
8. Copy of China hospital discharge summary, admission record and front page (no need to submit Claim Form II in the case of hospitalisation in China)
9. Copy of Meals breakdown

Additional documents (if applicable):

1. Copy of doctor’s referral for specialist or therapeutic treatment (if applicable)
2. Copy of Physiotherapy/Occupational therapy report (if applicable)
3. Copy of claims settlement advice from other insurer/party (if applicable)
4. Proof of claimant's bank account details with the account holder’s name and account number (e.g. copy of bank passbook, copy of debit card/EPS)
5. Telegraphic Transfer Request Letter

For HealthSure Hospital Income Plan only:

1. Supplement – Tax Residency Self-Certification for Individual/Non-Individual (For Claims)
2. IRS Form W-8 (for non-US entity/trust) / IRS Form W-9 (for US entity/trust)

CLAIMS SUBMISSION

1. Through Emma by AXA: Fill-in the form(s) and upload the supporting document(s) in Emma by AXA
2. By post: Mail the completed claim form(s) with all supporting document(s) to the mailing address listed on the claim form
3. Through Financial consultant assistance: Submit the completed claim form(s) with all supporting document(s) to your financial consultant