claim-eform | ព្រូដិនសលកម្ពុជា

Make a claim

All fields marked with * are mandatory

Select Claim Type

Claimant Details

Role

Details Regarding Claim Event

Happened To

Date of Claim Event (MM/DD/YYYY) *:

Payment Details

Required Documents

Claimant National ID Card *:

Claimant Bank Account Card *:

Death Certificate/Total and Permanent Disability Certificate *:

Medical Record/Police Report *:

Proof Relationship Document:

Does Life Assured also have life insurance policies with other companies?

Request Verification *

I guarantee that the information provided is true and accurate, and take all legal responsibility regarding the accuracy of this information. I authorize Prudential (Cambodia) Life Assurance PLC to store and share my data and sensitive information (name, bank account information, etc.) within Prudential (Cambodia) Life Assurance PLC and third-party banks to make claim payments.

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