AIA Evidence Request Form

Evidence Request Form

Applicable only for New Business application form which has been signed, submitted and received by the Company. This is not applicable for preliminary application.
INSURANCE ADVISER (IA) / INSURANCE REPRESENTATIVE (IR)’S PARTICULARS
Name*
Policy Number*
IA / IR Code*
Email*
example@aia.com.sg
Mobile Number*
APPLICANT’S PARTICULARS
Full Name*
NRIC (Last 3 Digits and alphabet) *
Gender*
Smoker*
Examination Address*

Street Address

Floor, Unit #, Building Name etc.

CityState / Province

Postal CodeCountry
Contact Number*
Examination Date and Time (First Preference)*
Examination Date and Time (Second Preference)
Note: There will be an additional charge of $50 payable by agent for appointment times after 3:30pm or on weekends/PH.
MEDICAL EXAMINATION
MaleFemaleNo preference
Adult ExaminationJuvenile Examination3 Blood Pressure Readings
Yes
BLOOD TEST
BPA*BPBBPCBPD*BPEBPF*BPHA*BPHBBPHCBPHF*FBS/HbA1c*Thyroid Function TestOGTT*FBC / pBFPSAHbeAgUric AcidHepatitis C AntibodyOther
I acknowledge that fasting is required for the tests I have chosen.
URINE TEST
Urine FEMEUrine FEME x 2 (separate occasions)Urine Culture
Yes
ADDITIONAL ITEMS
Please attach the AIA Underwriter memo here*

Cancelof
Remarks / Special Instructions (optional)
PLEASE NOTE:
1. The preferred times are subject to availability. Speedoc will try its best to allot the time selected, but due to high demand may offer a different appointment time.
2. Weekend (Sat & Sun) bookings must be made before Friday, 12:00 pm.
3. Appointments for Resting ECG and/or Adult and Juvenile medical examination is available daily from 8:00 am to 8:00 pm (including weekends).
4. If blood and/or urine tests are required, medical appointment must be made on weekdays (Mon –Fri) from 8:00 am to 3:00 pm only.
5. There will be an additional charge of $50 payable by agent for appointment times after 3:30pm or on weekends/PH.
6. Please be punctual for the appointment.
7. Any rescheduling and cancellation of appointments have to be done at least 24 hours before the scheduled booking.
8. If any the above is not met, there may be a surcharge incurred which will be borne by the advisor.
9. An island surcharge of $30 applies for locations in Sentosa, Jurong Island and Tuas.
10. Please have your client fill up the COVID-19 Declaration Form 1 day prior the appointment.
Signature

Clear
Date

DayMonthYear
Date
Please verify that you are human*
Should be Empty: