cfi-form | ព្រូដិនសលកម្ពុជា

Make a claim

Application/Policy

Cancellation Request

All fields marked with * are mandatory

Cancellation Reason

Please provide more details *

Policy or App Number*

Verification

to request for OTP on your registered contact number.

OTP Number *

Policy Owner Details

Whats your preferred payment method?

Bank Transfer

ID/Passport

Please specify your bank account details which you would like us to refund the premium back via ACLEDA Bank or other bank partners. *

Bank Name*

Bank Account Name *

Bank Account Number *

If you do not have bank account, please attach your valid national ID or Passport to Prudential (Cambodia) to proceed the refund. After that, you can withdraw in cash at ACLEDA bank’s branches by using that ID Card or Passport. *

Full name on ID/Passport *

ID/Passport Number *

Other supporting Documents

Remark: Please attach proof of relationship if you refund premium to third party (ex: Family Book, Residence Book, Married Certificate, etc.)

Upload Documents

I/We confirm that the information declared in this request is true, correct and adequate. *