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Find the important documents and forms you need to make our services easier. Especially for the policy data changes submission and withdrawal of life insurance investment funds, see the steps below:

Langkah-Langkah Formulir

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Step 1.
Complete the Preferred Application Form
Complete the application form according to the change or withdrawal of funds desired. You are required to fill out the form in full and detail according to the questions on the form.
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Step 2.
Attach requested Supplemental Documents along with the Submission Form
Attach all the necessary complementary documents in accordance with the desired submission such as a copy of the valid Policyholder's ID card, the original policy book (if applying for policy closure), and others.
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Step 3.
Submit Original Application Form to AXA Mandiri
The application form to be submitted is the original form is included with the policyholder's signature. If the application form has been filled out and all required documents are complete, please submit it to PT AXA Mandiri Financial Services (AMFS) through Financial Advisor (FA) or can be sent directly to:
PT AXA Mandiri Financial Services
AXA Tower Lt. 8 Jl. Prof. Dr. Satrio Kav. 18, Kuningan City Jakarta 12940, Indonesia
Customer Care Centre:
Tel: 1500 803

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Formulir Asuransi Mandiri Kesehatan Global

Formulir Klaim Nasabah (Rawat Inap/Rawat Jalan)-Asuransi Jiwa
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Formulir Klaim Meninggal Dunia (Dokter) Asuransi Jiwa
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Surat Pernyataan Pemegang Polis
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Formulir Admisi Rumah Sakit/Pra-Otorisasi – Asuransi Jiwa
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Formulir Klaim Perawatan Gigi – Asuransi Jiwa
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Formulir Asuransi Mandiri Corporate Health Plan

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Form Surat Pengajuan Klaim Meninggal – Asuransi Jiwa
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Form Surat Keterangan Dokter Klaim Meninggal Dunia – Asuransi Jiwa
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Formulir Lembar Pengajuan Klaim Rawat Jalan – Asuransi Jiwa
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Formulir Laporan Pemeriksaan Kesehatan – Asuransi Jiwa
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Formulir Resume Medis – Asuransi Jiwa
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Formulir Klaim Reimbursement (Rawat Jalan) – Asuransi Jiwa
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Form Surat Permohonan Perubahan Daftar Peserta – Asuransi Jiwa
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Mandiri International Medical Care

Formulir Klaim (Diisi Oleh Nasabah)-Asuransi Jiwa
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Formulir Klaim (Diisi Oleh Dokter)-Asuransi Jiwa
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Formulir Admisi Rumah Sakit Pra Otorisasi
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Download Formulir Keluhan Nasabah (Jiwa)

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Formulir Penanganan Keluhan Nasabah
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Asuransi Mandiri Perlindungan Penyakit Tropis

Formulir Klaim Nasabah (Rawat Inap/Rawat Jalan)-Asuransi Jiwa
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Formulir Klaim Kesehatan/Rawat Inap (Dokter)-Asuransi Jiwa
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Perubahan dan Penambahan Data Polis

Formulir Penghentian Perpanjangan Polis Asuransi Mandiri Jaminan Kesehatan
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Form Surat Kuasa Debet Kartu Kredit-Asuransi Jiwa
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Formulir Dana Investasi
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Formulir Perubahan Data Polis
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Form Surat Kuasa Debet Rekening – Asuransi Jiwa
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Formulir Pernyataan Penambahan Perubahan Informasi/Data – Asuransi Jiwa
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Formulir Pernyataan Kesehatan dan Perubahan Data Polis – Asuransi Jiwa
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Pengajuan Klaim (Jiwa)

Formulir Klaim Meninggal Dunia (Nasabah) - Asurasi Jiwa
(PDF, 1.26 MB)
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Formulir Klaim Kesehatan/Rawat Inap (Dokter)-Asuransi Jiwa
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Formulir Klaim Penyakit Kritis (Dokter) – Asuransi Jiwa
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Formulir Klaim Ketidakmampuan/Cacat (Dokter)-Asuransi Jiwa
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Formulir Klaim Meninggal (Dokter)-Asuransi Jiwa
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Formulir Klaim Kesehatan/Ketidakmampuan/PenyakitKritis – Asuransi Jiwa
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Formulir Asuransi Mandiri Kesehatan Prima

Formulir Admisi Rumah Sakit Pra Otorisasi
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Formulir Klaim Kesehatan/Rawat Inap (Dokter)-Asuransi Jiwa
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Formulir Klaim Nasabah (Rawat Inap/Rawat Jalan)-Asuransi Jiwa
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Surat Pernyataan Pemegang Polis
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Formulir Klaim Mandiri Travel

Formulir Klaim Mandiri Travel (Bahasa)
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Formulir Asuransi Mandiri Kesehatan Optima

Surat Keterangan Dokter (Rawat Inap - Rawat Jalan) Asuransi Jiwa
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Formulir Klaim Nasabah (Rawat Inap/Rawat Jalan)-Asuransi Jiwa
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Surat Pernyataan Pemegang Polis Mandiri Kesehatan Optima
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Download Formulir Keluhan Nasabah

Surat Pernyataan Penyelesaian Keluhan
(PDF, 122.71 KB)
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Formulir Penanganan Keluhan Nasabah
(PDF, 358.47 KB)
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Pengajuan Klaim

Travel Insurance Claim Form-General Insurance
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Motor Insurance Claim Form-General Insurance
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Formulir Klaim Non Kendaraan Bermotor – Asuransi Umum
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Formulir Klaim Kendaraan Bermotor – Asuransi Umum
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Formulir Klaim Kecelakaan Pribadi – Asuransi Umum
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Formuli Klaim Penyakit Kritis (Dokter) – Asuransi Jiwa
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Formulir Klaim Ketidakmampuan/Cacat (Dokter)-Asuransi Jiwa
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Formulir Klaim Meninggal (Dokter)-Asuransi Jiwa
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Formulir Klaim Kesehatan/Rawat Inap (Dokter)-Asuransi Jiwa
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Travel Insurance Claim Form-General Insurance
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Formulir Mandiri AXA Hospital Plan

Form Klaim Rawat Inap Mandiri AXA Hospital Plan
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Formulir Klaim Meninggal Dunia Mandiri AXA Hospital Plan
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Persyaratan Dokumen Klaim Asuransi Perjalanan

Persyaratan Dokumen Klaim Asuransi Perjalanan
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Surat Keterangan Ahli Waris untuk Pengajuan Penutupan Polis

Surat Keterangan Ahli Waris untuk Pengajuan Penutupan Polis
(PDF, 160.00 KB)
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Permohonan

Formulir Penutupan Asuransi Kendaraan Bermotor – Asuransi Umum
(PDF, 384.75 KB)
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Formulir Penutupan Asuransi Properti – Asuransi Umum
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Formulir Klaim Asuransi Kesehatan Mandiri AXA General Insurance (MAGI)

SmartCare Executive Claim Form Admedika
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SmartCare Executive Claim Form Fullerton Bill
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SmartCare Executive Claim Form OneAXA
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Pre Admission Form Malaysia
(PDF, 496.67 KB)
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Pre Admission Form Singapore
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Pre Admission Form Thailand
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Reimburse Claim Form (International Exclusive/Promedicare) Product
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Schedule of Procedure - April 2019
(PDF, 936.35 KB)
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PT AXA Mandiri Financial Services

PT AXA Mandiri Financial Services

AXA Tower Ground Floor
Jl. Prof. Dr. Satrio Kav. 18,
Kuningan City
Jakarta 12940, Indonesia

Customer Care Center:

Tel: 1500 803