Individual Business Agents and Partners
About Us

Forms Download

1 of 2

Life Insurance Forms

Letter of Consent - Disclose personal information of the Insured 206 KB
Direct Debit and Direct Credit request form 88 KB
OPD Claim Form 283 KB
AI-IPD-PA-CI Claim Form 291 KB
Payment Form (This form only available in Thai) 226 KB
New cheque Issuance Request Form 108 KB
Death Claim Form 2 MB
TPD Claim Form 1 MB
Complaint Receipt Form (This form only available in Thai) 78 KB
Letter to express your intent to buy My First Class @BDMS and to cancel MHP MHPE 83 KB
W-8 BEN (For non U.S. citizen or resident) 71 KB
W-8BEN-E (For non U.S. entity) 312 KB
W-9 (For U.S. entity or U.S. citizen or resident) 143 KB

2 of 2

Non-Life Insurance Forms

Complaint Receipt Form 941 KB
Appoint Policyholder to be Beneficiary Form 182 KB
Employee Benefits Manual 289 KB
Agreement on the use of Group Insurance ID Cards 123 KB
AI-IPD-PA-CI Claim Form 291 KB
Enrollment Request Listing Form for Group Life Insurance (New Business) 123 KB
Enrollment Request Listing Form for Group Life Insurance (New Business) 1 MB
Group Personal Accident Application Form (Policy holder) 172 KB
OPD Claim Form 283 KB
AI-IPD-PA-CI Claim Form 291 KB
Death Claim Form 2 MB

Forms Download (Aetna)

Letter of Assignment Form 168 KB
Claim Reimbursement Form for members 209 KB
Consent Form 215 KB
Physical Attending Report 402 KB
OPD Form 157 KB
Pre-Arrangement Form 141 KB
Admission Form 155 KB
HB Incentive Claim Reimbursement Form 140 KB
ATH Medical Claim Form 1009 KB
ATH Dental Claim Form 983 KB
ATH Personal Accident Claim Form 870 KB
ATH Compassionate Emergency Visit Form 764 KB
ATH Mortal Remains Claim Form 793 KB
ATH Maternity Claim Form 744 KB
Payment Form 995 KB
Application for Debiting a Deposit Bank Account 162 KB
Beneficiary changing request form 155 KB
Power of attorney form 165 KB
Letter of Consent of Automatic Recurring Payment 506 KB
Request form for the payment of insurance premiums certificate of Health and Personal Accident Insurance 140 KB
Hospital and Clinic List 1 MB
Request to amend information 211 KB
Upgrade form 182 KB
Membership Handbook-Individual Health Insurance 1 MB
UltraCare Plan guide – Individual 5 MB
UltraCare Plan guide – Group 5 MB
Superior Health 1 MB
Savvy Health 1 MB
Beyond Care Plan 754 KB
Max Care Plan 982 KB
Basic Care Plan 754 KB
Care Plus Plan 264 KB
Care Anywhere Plan 1 MB
Employee Care Plus Plan 336 KB
Extra Value Plan 841 KB
Travel Insurance 1016 KB
my health Allianz Ayudhya Leaflet 986 KB

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Plan

Application Form
Basic Care
Smarter Health
Exclusive Care @BDMS 		Personal Health and Accident Insurance Policy
(Maximum Benefit per policy year)
Beyond care
Superior Health
White Diamond 		Special Personal Health and Accident Insurance Policy
Care Anywhere
Care Plus 		Personal Health and Accident Insurance Policy (Top-Up)

Employee Care Plus

 Personal Health and Accident Insurance Policy (Worksite)

Max Care

 Personal Health and Accident Insurance Policy

Savvy Health

 Health and Accident Special Plus Insurance Policy
Extra Value Plan Form 197 KB
Travel Insurance Form 468 KB
Superior Health 1 MB
Savvy Health 1010 KB
Beyond Care 1 MB
Max Care 1 MB
Basic Care 1 MB
Care Plus 999 KB
Care Anywhere 1006 KB
Extra value (telesales) 1 MB
Extra Value 1 MB
Extra Value Plus 1 MB
Personal Care and Beyond Personal Care 1 MB
Platinum and Platinum+ 1 MB
vHealth vCare 959 KB
Extra Care 966 KB
Employee Plus 1 MB
Maximum Limit Per Year 980 KB
Maximum Limit Per Year (Telesales) 800 KB
Accident Plus 1 MB
Worldwide Travel Health Insurance Policy 7 MB
Smarter Health 1 MB
Exclusive Care @BDMS 1 MB

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