MOTOR VEHICLE INSURANCE

GENERAL CLAIM FORM (CLDC18002)

IMPORTANT, PLEASE READ: Submission of this form together with the supporting document/s is for evaluation purposes only. MAPFRE Insular Insurance
Corporation reserves the right to request for additional document/s & or information as needed to complete the review of this claim. List of required document/s
&/or information is provided at the back or page 02 of this claim form. This must not be construed as an admission of liability.

SECTION 01: POLICYHOLDER/INSURED

POLICYHOLDER/INSURED INFORMATION
NAME OF POLICYHOLDER/COMPANY:
POLICYHOLDER/COMPANY: POLICY NO.:

NAME OF INDIVIDUAL INSURED/CLAIMANT: CONTACT NO./MOBILE NO.:

COMPLETE ADDRESS OF INSURED/CLAIMANT: EMAIL ADDRESS:

SECTION 02: INSURED VEHICLE

VEHICLE INFORMATION
REGISTERED OWNER: YEAR, MAKE AND MODEL: PLATE NO. OR CS NO.:

CHASSIS NO.: ENGINE NO.: DATE OF PURCHASE:

SECTION 03: DRIVER INFORMATION & CLAIM DETAILS

NAME OF AUTHORIZED DRIVER AT THE TIME OF ACCIDENT: DRIVER'S LICENSE
LICENSE DETAILS:
LICENSE NO.:
VALIDITY PERIOD:
RESTRICTION/S:
LICENSE TYPE: □ Professional
RELATIONSHIP WITH THE INSURED:
INSURED: ____________________________________ □ Non Professional
CIRCUMSTANCE OF LOSS PLACE/DATE & TIME OF LOSS:

WHAT PURPOSE THE VEHICLE IS BEING USED FOR?

□ Personal use □ Hired by passengers
□ Commercial use □ Others (please specify) ________________
DAMAGES INCURRED BY THE INSURED UNIT (Please specify): EXTENT OF DAMAGE:
□ Minor □ Moderate □ Severe

PARTY AT FAULT:
□ Insured/Authorized Driver □ Third Party □ None

FRAUD WARNING OUR CONTACT INFORMATION:

Section 251 of the Insurance Code, as amended, imposes a fine not exceeding EMAIL ADDRESS: teleservice@mapfreinsular.com
twice the amount claimed and/or imprisonment of two (2) years, or both, at the OFFICE ADDRESS: MAPFRE | Insular Insurance Corporation - Claims Division
discretion of the court, to any person who represents or causes to be presented 9/F MAPFRE | Insular Corporate Center
any fraudulent claim for the payment of a loss under a contract of insurance, and Acacia Avenue, Madrigal Business Park
who fraudulently prepares, makes or subscribes any writing with intent to present Ayala Alabang, Muntinlupa City 1770
or use the same, or to allow it to be presented in support of any claim. CONTACT NO.: (+632) 8876 4400
WEBSITE: www.mapfre.com.ph
 MOTOR VEHICLE INSURANCE
GENERAL CLAIM FORM (CLDC18002)
SKETCH PLACE OF ACCIDENT AND LOCATION OF MOTOR VEHICLE/S AT THE TIME OF THE ACCIDENT:

SECTION 04: THIRD

THIRD PARTY VEHICLE INFORMATION
REGISTERED OWNER: YEAR, MAKE AND MODEL: PLATE NO. OR CS NO.:

NAME OF DRIVER: CONTACT NO.: INSURER OF THIRD PARTY VEHICLE:

SECTION 05: NAME OF INJURED PERSON/S DUE TO VEHICULAR ACCIDENT:

NAME OF INJURED PERSON/S:
PERSON/S: IDENTITY OF INJURED PERSON INJURY SUSTAINED: CONTACT DETAILS OF VICTIM/FAMILY MEMBER:
□ Insured's passenger □ Minor injury
□ TP's passenger □ Serious injury
□ Pedestrian □ Death
□ Insured's passenger □ Minor injury
□ TP's passenger □ Serious injury
□ Pedestrian □ Death
□ Insured's passenger □ Minor injury
□ TP's passenger □ Serious injury
□ Pedestrian □ Death
REMARKS:

SECTION 06:
06: DECLARATION AND AUTHORIZATION
TRUTHFULNESS
This is to certify that to the best of my knowledge, all the information provided in this Claim Form is true, complete and correct.
I understand that it may be necessary to verify the information submitted to support my claim.
AUTHORIZATION
I hereby authorize MAPFRE Insular Insurance Corporation or its representative to verify the accuracy and truthfulness of document/s &/or
information provided from the issuing establishment &/or from competent authorities who have personal knowledge regarding this claim. I
hereby irrevocably authorize MAPFRE Insular Insurance Corporation or its representative to obtain my/our record related to the vehicular
accident from attending traffic enforcer, police officers, medical practitioner, clinics hospital, insurance companies, government
agencies/institutions and other relevant organization or establishment. This authorization is valid even i/we am/are deceased. My/our next kin
is also bound by this authorization. The original copy of this authorization has the same effects.
DATA PRIVACY
By submitting this application form, I hereby agree and consent that to the extent required by law, MAPFRE Insular Insurance
Corporation may collect, use, and process my personal information in accordance with the Data Privacy Act of 2012.
SIGNATURE OVER PRINTED NAME: DATE SIGNED:

FRAUD WARNING OUR CONTACT INFORMATION:

Section 251 of the Insurance Code, as amended, imposes a fine not exceeding EMAIL ADDRESS: teleservice@mapfreinsular.com
twice the amount claimed and/or imprisonment of two (2) years, or both, at the OFFICE ADDRESS: MAPFRE | Insular Insurance Corporation - Claims Division
discretion of the court, to any person who represents or causes to be presented 9/F MAPFRE | Insular Corporate Center
any fraudulent claim for the payment of a loss under a contract of insurance, and Acacia Avenue, Madrigal Business Park
who fraudulently prepares, makes or subscribes any writing with intent to present Ayala Alabang, Muntinlupa City 1770
or use the same, or to allow it to be presented in support of any claim. CONTACT NO.: (+632) 8876 4400
WEBSITE: www.mapfre.com.ph
 MOTOR VEHICLE INSURANCE
GENERAL CLAIM FORM (CLDC18002)
CLAIM PROCEDURE & LIST OF DOCUMENTS REQUIRED: REQUIRED:
IMPORTANT: STANDARD REQUIREMENTS (FOR ALL TYPES OF CLAIM):
1. Please prepare the required documents together with the 1. Duly accomplished and signed MIIC Claim Form;
copy of your policy and proof of premium payment before 2. Copy of driver's license and OR of driver at the time of accident;
reporting a claim to facilitate verification; 3. Copy of certificate of registration and OR of insured unit;
2. Claim must be reported the soonest possible time after the 4. Copy of deed of sale if the name insured is different from the
accident, late reporting may cause delay in the processing of registered owner;
your claim and you shall be required to submit an explanation 5. If the damage/s incurred by your insured unit was caused by a third
regarding the cause of delay; party OR you caused damages to a third party vehicle OR a third party
3. Only the name insured &/or registered owner is allowed to vehicle/person is involved, submit certified true copy or original copy of
sign the pertinent documents regarding this claim, the insured police report with sworn statement;
must issue a special power of attorney to his/her authorized 6. Optional - photographs of the insured unit showing the following:
representative in his/her absence. a. Front, back, left side & right side of insured vehicle (plate
no./conduction shown);
MODES OF REPORTING A CLAIM: b. Close-up photos of damaged parts.
1. Via call - call our contact number (02)876-4400 (available 7. Optional - copy of repair estimate from MIIC accredited shops.
24/7);
2. Via website - visit www.mapfre.com.ph ADDITIONAL REQUIREMENTS:
THIRD PARTY PROPERTY DAMAGE (TPPD):
SUBMISSION OF REQUIRED DOCUMENTS: 1. Copy of TP driver's license and OR of driver at the time of accident;
1. Copy may be submitted online via our web portal, 2. Copy of TP certificate of registration and OR of insured unit;
instructions will be given during the call; 3. Optional - photographs of TP unit showing the following:
2. Original copy of required documents must be submitted via a. Front, back, left side & right side of insured vehicle (plate
courier or personal delivery to the following address: no./conduction shown);
b. Close-up photos of damaged parts.
MAPFRE | Insular Insurance Corporation (MIIC) - Claims Division 4. Optional - copy of repair estimate from MIIC accredited shops;
8/F MAPFRE Insular Corporate Center 5. Original copy of Certificate of No Claim from TP insurer.
Acacia Avenue, Madrigal Business Park THIRD PARTY BODILY INJURY (TPBI):
Ayala Alabang, Muntinlupa City 1170 1. Certified true copy or original copy of medical certificate;
2. Copy of related hospital records, such as but not limited to laboratory
NOTES: test results, medical abstract, discharge summary, prescription slips, etc.;
1. During the call you will be informed of the list of our 3. Original official receipts of medical expenses;
accredited repair shops near your area or near your preferred 4. Original copy of release of claim and/or affidavit of desistance signed by
location and the schedule of inspection; TP;
2. You will receive an email to update you regarding your claim; 5. In case of death, death certificate and proof of beneficiary such as NSO
3. If you have queries regarding your claim, you may call our certified marriage certificate, birth certificate must be submitted;
hotline (02)8876-4400 or send it to 6. Copy of 1 valid ID with 3 specimen signature.
teleservice@mapfreinsular.com.

FRAUD WARNING OUR CONTACT INFORMATION:

Section 251 of the Insurance Code, as amended, imposes a fine not exceeding EMAIL ADDRESS: teleservice@mapfreinsular.com
twice the amount claimed and/or imprisonment of two (2) years, or both, at the OFFICE ADDRESS: MAPFRE | Insular Insurance Corporation - Claims Division
discretion of the court, to any person who represents or causes to be presented 9/F MAPFRE | Insular Corporate Center
any fraudulent claim for the payment of a loss under a contract of insurance, and Acacia Avenue, Madrigal Business Park
who fraudulently prepares, makes or subscribes any writing with intent to present Ayala Alabang, Muntinlupa City 1770
or use the same, or to allow it to be presented in support of any claim. CONTACT NO.: (+632) 8876 4400
WEBSITE: www.mapfre.com.ph