Aviva Ltd dental claim form at a glance
What it is: This is the Aviva Ltd dental claim form: the patient is required to pay the dentist and attached receipt to seek reimbursement from Aviva Ltd.
Who signs: Section I is to be completed by Employee. Sign at EMPLOYEE'S SIGNATURE. Section II is to be completed by DENTIST. The dentist enters the Name of Dentist, the DENTIST'S SIGNATURE & CLINIC'S STAMP and the DATE.
A filled-in Aviva Ltd dental claim form example: an employee claims her own treatment
How to fill out Aviva Ltd dental claim form, box by box
Section I: the employee and the company
In Section I, to be completed by the employee, enter the Name of Company and the Policy/Card Number.
Enter the Commencement of employment (dd/mm/yyyy), the Market unit/Dept and the Daytime Contact No. (Mobile/Pager/Tel).
The patient
Enter the Name of Patient, the NRIC/BC/FIN No. of Patient, the Sex M/F and the Date of Birth (dd/mm/yyyy).
If the patient is not the employee, enter the Name of Employee, the NRIC/FIN No. of Employee, the Sex M/F and the Date of Birth (dd/mm/yyyy). If the patient is not the employee, also enter the Relationship, which is only Wife, Husband, Son or Daughter.
Your bank account
All reimbursements will be credited into your payroll's bank account; please furnish your bank account number only if there are recent changes to your bank account: Name of Bank, Branch Name / Branch Code and Account Number.
To expedite reimbursement, please provide your bank account for direct credit into your account.
A payment advice will be sent upon credit to your bank account.
Employee's signature
Sign at EMPLOYEE'S SIGNATURE.
Enter the Office email address (If available).
Section II: treatment, completed by the dentist
Section II is to be completed by DENTIST.
Enter the Date of Treatment, then for each TYPE OF TREATMENT the AVIVA Office Code, the No. of Tooth Treated and the Amount Incurred, or Others (please indicate tooth number) and the Amount Incurred.
Dentist's name, signature and date
The dentist enters the Name of Dentist, the DENTIST'S SIGNATURE & CLINIC'S STAMP and the DATE.
Common questions about Aviva Ltd dental claim form
Where do I file it?
Employee to pay the dentist after treatment and attached your receipt together with the completed claim form and submit to: Aviva Ltd Group Life & Health Claims 4 Shenton Way #01-01 SGX Centre 2 Singapore 068807
Sources
[1] Aviva Ltd dental claim form, as served on this page (the Official source link on this page).