REQUIREMENTS FOR COCOLIFE/PHILPLANS CLAIMS

o CERTIFIED TRUE COPY OF DEATH CERTIFICATE (DECEASED) – 2 COPIES (ORIGINAL)

o BIRTH CERTIFICATE (DECEASED) – 2 COPIES (PHOTOCOPY)
o MARRIAGE CONTRACT – 2 COPIES (PHOTOCOPY)
o BIRTH CERTIFICATE (CHILDREN) – PHOTOCOPY
o VALID ID OF BENEFICIARY – 2 COPIES (PHOTOCOPY)
o VALID ID OF THE DECEASED MEMBER – 2 COPIES (PHOTOCOPY)
o PAYSLIP (ORIGINAL)
o PHOTOCOPY OF RECEIPT OF BURIAL/INTERMENT EXPENSES
 CERTIFICATE OF CLAIMANT/S
Instructions:
This certificate must be accomplished by the beneficiary/ies of legal age to whom the insurance proceeds
are payable. If the insurance proceeds are payable to minor/s, the certificate must be accomplished by his/her legal
or judicial guardian, an official certificate of whose appointment and qualification must be submitted. If any
beneficiary has died, a certified copy of the death certificate of such beneficiary must be submitted. Every question
must be distinctly and fully answered.

A. GENERAL DATA OF DECEASED

1. Full Name (Please print) ___________________________________________________
b. If deceased was a married woman, state maiden name ______________________________
2. a. Date of birth __________________ b. Place of birth ______________________________
c. Source from which date of birth was obtained _____________________________________
(Family record or other record of certificate of birth should be referred to)
3. Residence at death ____________________________________________________________
4. a. Date of death _________________ b. Cause of death _____________________________
5. a. Occupation at date of death ___________________________________________________
b. Date deceased last attended his usual work ______________________________________

INSURANCE POLICIES OF DECEASED

Name of Company Policy Number Date Issued Amount

___________________ _________________ _______________ ________________
___________________ _________________ _______________ ________________
___________________ _________________ _______________ ________________

B. HEALTH HISTORY OF DECEASED

1. Date deceased first complained or showed symptoms of last illness _________________
2. Date deceased first consulted a physician for his last illness _______________________
3. Names and addresses of all physicians consulted by the deceased during the last three years
and of, hospitals or other institutions where the deceased was confined or received treatment
within the last three years:

Name of Address Date of Attendance/ Illness/Condition

Physician/Hosp./Institution Confinement
From To
______________________ _____________________ ___________________ ________________
______________________ _____________________ ___________________ ________________
______________________ _____________________ ___________________ ________________

==================================================

CERTICATE OF AUTHORIZATION

This authorizes THE UNITED COCONUT PLANTERS LIFE ASSURANCE CORPORATION

and/or is duly authorized representatives to secure whatever information or records are available from government
and private hospitals and offices. This authorization is being made in connection with a claim on the insurance
policy or policies issued by the insurance company on the life the deceased.

It is understood that any action you may take in connection with this authorization releases you or any and
all members of your staff from any responsibility or obligation with the release of such records of information.

_____________________________ _________________________
Witness Beneficiary-Claimant
(Please sign over Printed Name) (Please sign over Printed Name)

CLAIMS-008-0417-5
C. BENEFICIARY/IES – CLAIMANT/S
Are you electing one of the optional modes of settlement in lieu of an immediate cash
payment? _________________ If so, which mode of settlement? _______________
(Not applicable if the claim does not involve a lump sum cash payment)

The undersigned hereby make/s claim to the insurance benefits of the deceased in the
UNITED COCONUT PLANTERS LIFE ASSURANCE CORPORATION and agree/s that
the written statements and affidavits of all the physicians who attended or treated the
deceased and all other papers called for by instructions hereon, shall constitute, and they are
hereby made a part of, these Proofs of Death, and further agree/s that the furnishing of this
form, or of any other forms supplemental hereto, by said Company shall not constitute nor be
considered an admission by it that there was any insurance in force on the life in question,
nor a waiver of any of its rights to defense.

Full Name Date of Birth

Relationship Signature
to deceased
_____________________ _________________ _______________ _________________
_____________________ _________________ _______________ _________________
_____________________ _________________ _______________ _________________
_____________________ _________________ _______________ _________________
_____________________ _________________ _______________ _________________
_____________________ _________________ _______________ _________________

Contact No. _________________ Date Accomplished ___________________

Basic Requirements:
The following documents should also be submitted:
1. Death Certificate
2. Policy Contract
3. Birth Certificate of Insured
4. Proof of Relationship of Beneficiary
The Company reserves the right to require or obtain further information should it deem
necessary.

(Avoid expense: It is not necessary to employ the service of a person, firm or corporation regarding this claim.
Write to: Claims Department, COCOLIFE Building, 6807 Ayala Ave., Makati City; or contact our provincial
office nearest your residence. It is our duty to expedite action on this claim. We do not charge for this service.)

“Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or imprisonment
of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for
the payment of a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to
present or use the same, or to allow it to be presented in support of any claim.”
 CERTIFICATE OF ATTENDING PHYSICIAN
MADE TO

(Before Making out this statement, read instructions at the back of this sheet.)
ALL QUESTIONS TO BE ANSWERED IN FULL

1. a. Deceased’s name in full b. Occupation: at death Prior thereto

c. Residence at No. Street City or Town Province

time of death
2. a. Age of Deceased b. Sex c. Height d. Approximate weight e. Color of hair
at death in health
f. Were there any identification marks on the body? Yes__ No__ If yes, give particulars

3. How long had you known deceased?

4. a. Date of Death b. Place of Death (If in hospital or institution, give name.) c. Length of hospitalization

5. a. When were you first consulted for the condition which either Who consulted you? (Specify if Date of last
directly or indirectly caused death? deceased, relative or others visit:

b. What was the immediate cause of death? (See instructions on reverse side.)

c. How long, in your opinion, did deceased suffer from this disease or impairment?

d. What were the contributory causes of death? Give below, the duration of each: (See instruction on reverse side)
Disease or Impairment Duration

e. Was there any special connection (remote or proximate) between the death and the occupation, residence, habits
or personal history of the deceased? ___ Yes ___ No If yes, state which and give particulars.

6. Give below particulars of each condition for which you treated or advised deceased prior to last illness:
Nature of Condition Date Duration Result of treatment

7. Give names and addresses of other physicians and other practitioners who to your knowledge attended deceased
during the past three years:
Name Address Disease or Impairment and Date

8. a. Was death due to suicide, homicide, or accident?

b. Was deceased under the influence of liquor or drugs when accident/suicide/homicide happened? Yes ___ No ___

9. Was there an official inquiry as to cause of death or a post mortem examination on the body of the deceased?
___ Yes ___ No If yes, which, by whom and with what result?

Dated at this day of ,20

Physician’s Name in print Physician’s Signature

License No. (Privilege Tax) Date Physician’s Address

Witnessed by Witness Address

CLAIMS 048-0517-2
 INSTRUCTIONS

ALL ANSWERS MUST BE ENTIRELY IN THE PHYSICIAN’S OWN HANDWRITING.

In the interest of accurate vital statistics, please conform to the International List of the causes of death
when answering Question 5.

If an injury, describe the accident. If a suicide or homicide, state the means employed.

In surgical cases, state the nature of operation and the disease or condition requiring such procedure. In
females, puerperal states are to be indicated. In neoplasm, give type part first involved. Please avoid indefinite
terms. Describe any unusual features.

Where spaces provided for the answers are too small, such details as seen desirable should be given
below.

“Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or
imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be presented any
fraudulent claim for the payment of a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes
any writing with intent to present or use the same, or to allow it to be presented in support of any claim.”