PRUextra Claim Form

Reg.
No 199002477Z
PRUEXTRA CLAIM FORM

The Company does not admit liability by the mere submission of this form and the required documents.
This form is to be completed by the Life Assured who is at least 18 years old or the
policy owner
Required if the
documents for Life
claimAssured is below 18 years old.
submission:
Required documents for claim submission:

1. PRUExtra Claim Form (all questions must be completed)
2. Original final hospital bill, tax invoice and receipt
3. Copy of Medisave statement stating the Hospital Registration Number (if the bill is paid by Medisave)
4. Copy of relevant Payslip if you are covered under the civil service medical benefit scheme with co-payment
If the Life Assured is deceased, please also provide us with the following documents:
1. Death Claim Claimant’s Statement
2..Death certificate issued by the relevant authority
3. Copy of the identification documents of the claimant
4. Evidence that the person is entitled to receive the payment. (e.g birth certificate, marriage certificate, the
deceased’s last will, Letter of Administration or Probate, Trust Deed etc.
Important Note: Please note that, under the policy terms and condition, the policy may be void if any
information provided in this claim form are made knowingly by you that it is materially false or
misleading.
PRUExtra Policy No.
LIFE ASSURED’S PARTICULARS
Full Name NRIC No
Address
Contact No
TYPE OF CLAIM
Please tick the relevant box and provide the information required in the following:
Tick Type of Benefit Claim Date of Date of Date of Birth

Hospitalisation/ Diagnosis/ of Child
Surgery Consultation
(dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy)
☐ Daily Hospital Incentive NA NA

☐ Accident & Emergency Ambulance fee* NA NA
☐ Immediate family member’s accommodation NA NA
with child*
☐ Special Appliances & Prosthesis* NA NA
☐ Traditional Chinese Medicine Treatment* NA NA
☐ Outpatient Psychiatric Treatment (Postpartum)* NA
☐ Autism Test* NA NA
☐ Recurrent Miscarriage (Cost of Investigation)* NA NA
☐ Emergency Outpatient Due to Accident* Please complete the information on next page
* These benefits are not applicable to PruExtra Lite and PruExtra Preferred Co Pay.
Page 1 of 3 PS Apr 2022

ID CMHSCLM
CLAIM DETAILS
For Emergency Outpatient Treatment due to Accident:
All information below must be furnished.
Date of accident dd/mm/yyyy Time of accident am / pm
Place of accident
Detailed description of accident.
Description of the nature and extent of your injury.
Important Information to Note:
Special Appliances & Prosthesis

It is mandatory to submit a prescription from the Life Assured’s treating doctor for such purchase.
Outpatient Psychiatric Treatment (Postpartum)

Copy of the child’s birth certificate is required.
Please be advised that we only cover for eligible medical expenses up to 12 months from the date of birth of the
child and treatment is from a registered psychiatrist or psychologist registered with the Singapore Register of
Psychologists (SRP), who is not the policyowner, the life assured or a family member of either.
It is mandatory to submit a medical report or medical memo from the Life Assured’s treating psychiatrist or
psychologist [registered with the Singapore Register of Psychologists (SRP)], stating the diagnosis, date of
diagnosis and the treatments provided.
Autism Test
Applicable only if Life Assured is below the age of five (5) years.
It is mandatory to submit a medical report or medical memo from the life assured’s Paediatrician stating the
diagnosis, date of diagnosis and the treatments provided.
Recurrent Miscarriage (Cost of Investigation)

Applicable only if the Life Assured suffers from three or more miscarriages.
A doctor’s letter is required as supporting information, along with details of current investigations.
Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore 049712
Postal Address: Robinson Road P.O. Box 492 Singapore 900942
Telephone: 6535 8988 Fax: 6734 9555 Website: www.prudential.com.sg
Part of Prudential Corporation plc Reg. No 199002477Z


PRUextra Claim Form

Uploaded by

Copyright:

Available Formats

PRUextra Claim Form

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PRUextra Claim Form

Uploaded by

Copyright:

Available Formats

Reg.

PRUEXTRA CLAIM FORM

Required documents for claim submission:

PRUExtra Policy No.

LIFE ASSURED’S PARTICULARS

Full Name NRIC No

Tick Type of Benefit Claim Date of Date of Date of Birth

☐ Daily Hospital Incentive NA NA

Page 1 of 3 PS Apr 2022

For Emergency Outpatient Treatment due to Accident:

All information below must be furnished.

Date of accident dd/mm/yyyy Time of accident am / pm

Detailed description of accident.

Description of the nature and extent of your injury.

Important Information to Note:

Special Appliances & Prosthesis

Outpatient Psychiatric Treatment (Postpartum)

Recurrent Miscarriage (Cost of Investigation)

Page 2 of 3 PS Apr 2022

You might also like