[SG] AIA Evidence Request Form

AIA SINGAPORE

* Applicable only for New Business application form which has been signed, submitted and received by the Company.

This is not applicable for preliminary application.

Please enter the details below and our team will get back to you with a confirmation soon.
INSURANCE ADVISER (IA) / INSURANCE REPRESENTATIVE (IR)'S PARTICULARS
Name:*
Policy Number:*
IA / IR Code:*
Email*
johndoe@speedoc.com
Mobile Number:*
CLIENT'S PARTICULARS
Full Name:*
(As per NRIC)
Client's Mobile Number:*
NRIC / FIN / Passport Number:*
(Last 3 digits and alphabet only)
Address for Examination:*
* Island surcharge of $43.60 applies for locations including Jurong Island, Tuas, and Sentosa.
Gender:*

MaleFemale
Does client smoke?*

YesNo
MEDICAL EXAMINATION
Medical Examination Required?*

YesNo
Preferred Gender of Doctor?*

MaleFemaleNo Preference
Tests Required:*

Adult ExaminationJuvenile Examination3 Blood Pressure Readings
Any Further Tests Required?

YesNo
Resting ECG Required?*

YesNo
What are the additional tests required?
(If there are additional tests required, kindly indicate in this section, thank you).
BLOOD TEST - * denotes fasting is required
Tests Required:*

BPA*BPBBPCBPD*BPEBPF*BPHA*BPHBBPHCBPHF*FBS/Hba1c*Thyroid Function TestOGTT*FBC/PBFPSAHbeAgUric AcidHepatitis C AntibodyOthers
What are the other tests required?
(If there are additional tests required, kindly indicate in this section, thank you).
Urine - during non-menstruation
Tests Required:*

Urine FEMEUrine FEME x 2 (separate occasions)Urine CultureUrine Cotinine
PREFERRED APPOINTMENT DATE AND TIME
Preferred Appointment Date*

DayMonthYear
Date
Preferred Appointment Time*

9.00 am - 12.00 pm12.00 pm - 3.00 pm3.00 pm to 6.00 pm (surcharges may apply)
UPLOAD ATTACHMENT
Please attached screenshot or soft copy of underwriting form.*

Cancelof
TERMS AND CONDITIONS
1. Appointments must be made at least 2 weeks in advance.
2. Appointments may only be made between Monday to Friday, 9 am to 6 pm.
3. Surcharges will apply for appointments between 3 pm to 6 pm.
4. A surcharge of $43.60 for nurse appointments and $65.40 for doctor appointments will apply if scheduled on a public holiday.
5. You are advised to be punctual for the appointment.
6. All rescheduling and cancellations must be made at least 24 hours before the scheduled appointment.
7. If any of the above requirements are not met, a surcharge may apply and will be borne by the Agent.
8. Kindly encrypt your file and email to Speedoc by writing to medicalscreening@speedoc.com
9. Speedoc’s General Terms and Conditions of Service(s) can be found at https://speedoc.com/sg/terms (“Terms of Use”) and may be amended from time to time.
10. For more information, contact our team at +65 6909 7799.
I agree to the above Terms and Conditions.
Please verify that you are human*
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