Etiqa-Claimant's Statement V1-0

CLAIMANT'S STATEMENT
TO : ETIQA PHILIPPINES
I hereby claim for benefit under the Insurance Certificate/Policy(ies) of this Company numbered
. All the f ollowing answers and statements are true, correct and complete according
to my personal knowledge and belief. I understand that furnishing of this form and other claim forms by the
Company does not constitute an admission that there is any insurance in force.
1. (a) Full Name of the Deceased:

(b) Residence of the Deceased:
(c) Name and Address of Employer:
(d) Date deceased last attended his/her usual work:
(e) Occupation at date of death:
2. (a) Date of Birth: (b) Place of Birth:
3. (a) Date of Death: (b) Place of Death:

(c) Cause of Death:
(d) Date and Place of Interment:
4. (a) Date deceased first complained or showed symptoms of last illness:

(b) Names and addresses of all physicians who attended the deceased for the injuries sustained or during his
last illness and during the three years immediately preceding it and/or hospitals or other institutions
where the deceased was confined or received treatment within the last three (3) years.
Name of Physician Date of
and Hospital Address Confinement Disease/Illness
5. Was death due to Suicide, Homicide, Accident, Occupational Accident? If so, described briefly:
6. If deceased was insured with other Companies, please state:

Name of Company Certificate/Policy Number Amount of Insurance
TO WHOM IT MAY CONCERN

This authorizes Etiqa Philippines or its authorized representative to secure whatever information or
records you have regarding the illness or injury f or which the deceased
has been treated or examined. This authorization is being made in connection with any claim on the
insurance Certif icate/Policy issued by said insurance company on the life of the deceased.
This authorization discharges you or authorized member of your staff from any responsibility or
obligation in connection with the release of such record or information.
Signed at this day of , .
PRINTED NAME OVER SIGNATURE OF PRINTED NAME OVER SIGNATURE OF

WITNESS CLAIMANT
RELATION TO THE
DECEASED
*** see back page ***
Page 1 of 2
CLAIMANT'S STATEMENT
8. What is your date of birth? (If married, please submit Marriage Contract.)
9. If you are f iling this claim in behalf of minor beneficiaries, please give names and dates of birth and your
relation to them. (State such as father, mother, grandfather, etc.)
Minor's Name Date of Birth Relationship
10. As f ather/mother of said minor(s), have you not been disqualified by a court of law from
exercising the right to administer the property of such minor(s)? Yes No .
_______________________________________________________________________________________________
_____________________________________________________________________________________________
Signed at day of , .
Minor's Name Date of birth Relationship
___________________________________ ___________________ _________________________________
___________________________________ ___________________ _________________________________
___________________________________ ___________________ _________________________________
___________________________________ ___________________ _________________________________
__________________________________________ ___________________________________________
SIGNATURE OVER PRINTED NAME OF WITNESS SIGNATURE OVER PRINTED NAME OF CLAIMANT
A CK NOWL EDGEMENT
SUBSCRIBE AND SWORN to before me this day of , by the
above claimant who exhibit to me his/her Residence Certificate No. issued at
on .
Loc. No: Book

No.____________________
Page No. Series of
___________________
NOTARY PUBLIC
My commission Expires
on
Form No. GID-115
IMPORTANT NOTICE
"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 subscribe any writing with intent to present or use the same, or to
allow it to be presented in support of any claim."
Page 2 of 2

Etiqa-Claimant's Statement V1-0

Uploaded by

Copyright:

Available Formats

Etiqa-Claimant's Statement V1-0

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Etiqa-Claimant's Statement V1-0

Uploaded by

Copyright:

Available Formats

CLAIMANT'S STATEMENT

1. (a) Full Name of the Deceased:

3. (a) Date of Death: (b) Place of Death:

4. (a) Date deceased first complained or showed symptoms of last illness:

6. If deceased was insured with other Companies, please state:

TO WHOM IT MAY CONCERN

PRINTED NAME OVER SIGNATURE OF PRINTED NAME OVER SIGNATURE OF

* see back page *

Minor's Name Date of birth Relationship

_________________________ _ _________________________

_________________________ _ _________________________

_________________________ _ _________________________

_________________________ _ _________________________

SUBSCRIBE AND SWORN to before me this day of , by the

above claimant who exhibit to me his/her Residence Certificate No. issued at

Loc. No: Book

Form No. GID-115

You might also like