NOTICE OF CLAIM

DATE

Gentlemen:

This is to inform you that _______________________________________________, insured

with your office under LRP²/ AP³/ AD⁵ COC No. _______________:

[ ] died on _________ due to __________________________________________________

[ ] has been totally and permanent disabled due to _______________________________
[ ] suffered dismemberment on _________________ 20_____ due to:________________
[ ] both hands or both feet or sight of both eyes
[ ] either hand or foot and sight of one eye
[ ] one hand and one eye

Please advise us on the claim documents needed for the payment of his/her benefit.

Very truly your,

______________________________________________________

______________________________________________________
(Relationship with the Deceased/Insured)
 NOTICE OF CLAIM FOR DEATH BENEFIT

_______________________________
DATE

The Chief, Claims Adjustment Division

PCIC-Regional Office No. __________

Dear Sir/Madam:

Please facilitate the processing of the death benefit of my _____________________________________________

RELATIONSHIP
Mr./Mrs. _______________________________________ who died on______________________________________
NAME OF ASSURED DATE

due to ___________________________________________________________________.
CAUSE OF DEATH

Attached are the following documents for you ready reference:

1
2
3

Thank you.
Very truly yours,

_______________________________

_______________________________
Signature of Beneficiary
 Requirements in Death Claim
Please provide the following:

Notice of Claim
DEATH CERTIFICATE (Duly signed & sealed by the Local Civil Registrar)
Birth Certificate or any legally valid evidence of age of the insured.
Claimant Statement Form (hereto attached) to be accomplished by the
Manager of the lending institution/creditr (FOR LRP ONLY)
Police Report (if the cause of death is accident)
Marriage Contract (if the beneficiary is spouse)
Birth Certificate of Beneficiary (If the beneficiary is child)
Loan Payment History / Statement of Account
Other Documents such as sworn affidavit of two (2) disinterested persons
as maybe required by PCIC.

Requirements in Death Claim

Please provide the following:

Notice of Claim
DEATH CERTIFICATE (Duly signed & sealed by the Local Civil Registrar)
Birth Certificate or any legally valid evidence of age of the insured.
Claimant Statement Form (hereto attached) to be accomplished by the
Manager of the lending institution/creditr (FOR LRP ONLY)
Police Report (if the cause of death is accident)
Marriage Contract (if the beneficiary is spouse)
Birth Certificate of Beneficiary (If the beneficiary is child)
Loan Payment History / Statement of Account
Other Documents such as sworn affidavit of two (2) disinterested persons
as maybe required by PCIC.

Requirements in Death Claim

Please provide the following:

Notice of Claim
DEATH CERTIFICATE (Duly signed & sealed by the Local Civil Registrar)
Birth Certificate or any legally valid evidence of age of the insured.
Claimant Statement Form (hereto attached) to be accomplished by the
Manager of the lending institution/creditr (FOR LRP ONLY)
Police Report (if the cause of death is accident)
Marriage Contract (if the beneficiary is spouse)
Birth Certificate of Beneficiary (If the beneficiary is child)
Loan Payment History / Statement of Account
Other Documents such as sworn affidavit of two (2) disinterested persons
as maybe required by PCIC.