INSTRUCTIONS TO CLAIMANTS

FOR GROUP TERM LIFE INSURANCE

At the death of the insured individual, the completed claim forms as enumerated below, should be sent to the
Group Administration of Etiqa Philippines. Your cooperation in following the Instructions outlined below will
aid in the prompt adjudication of a claim. AVOID EXPENSES, it is not necessary to employ the services of a
person, firm or corporation regarding any claim. It is our duty to expedite action on this claim. We do not
charge for this services.

1. CLAIMANT'S STATEMENT (Form No. GID-115)

a. This form must be accomplished by the beneficiary/ies to whom the insurance proceeds are
payable. If there are more than one beneficiaries, a separate form must be accomplished by
each.
b. If the insurance proceeds are payable to a minor, the form must be accomplished by his/her
legal or judicial guardian, an official statement whose appointment and qualification must be
submitted.
c. If any beneficiary is dead, a certified copy of the death certificate of such beneficiary must be
submitted.
d. If the insurance proceeds or any part of it is payable to "children" or others of a class, a sworn
statement must be submitted giving the name and date of birth of each child. If any have died,
the statement must give the date and place of death, and must also state whether they died
unmarried, intestate and without issue.

2. ATTENDING PHYSICIAN'S STATEMENT (Form No. GID-117)

This form must be accomplished by every physician who attended to the deceased during his last
illness. For this purpose, the Company will furnish as many copies of this form as required

3. IDENTIFYING WITNESS' STATEMENT (Form No. GID-118)

This form must be accomplished by a person of legal age, intimately acquainted with but not
related to the deceased, who has seen the remains and has no interest in the proceeds of the
claim.

4. POLICYHOLDER'S STATEMENT (Form No. GID-119)

This form must be fully completed and signed by the authorized officer of the Group Policyholder.
The answer to Question No. 6 convey additional information necessary on a Master Policy
issued to an Association, Union, Trust or Club, etc.

All the foregoing forms must be properly dated and witnessed by a competent person of legal age. If death
occurred outside the Philippines, a statement from a diplomat or consulate representative of the Philippines
duly certified should also be submitted.

THE COMPANY RESERVES THE RIGHT TO REQUIRE OR OBTAIN FURTHER

INFORMATION SHOULD IT DEEMED NECESSARY

Besides proper accomplishment and submission of the above- prescribed Company's claim forms, the
following documents marked X should be submitted also:

X Death Certificate duly sealed and signed by the Office of the Local Civil Registrar.
Birth and / or Baptismal Certificate of the deceased-Insured and designated Beneficiary
X Marriage Certificate Certificate of Insurance
X
Letter of Guardianship - proof of judicial appointment of a guardian of the minor beneficiaries, if
amount of proceeds is more than P 50,000.00.
Affidavit of Guardianship to be executed by the Natural Parent.
Police Investigation Report (If cause of death was due to accident, Murder or Homicide).
Autopsy Report / Post Mortem Findings

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 CLAIMANT'S STATEMENT
TO : ETIQA PHILIPPINES

I hereby claim for benefit under the Insurance Certificate/Policy(ies) of this Company numbered
. All the following 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 for which the deceased
has been treated or examined. This authorization is being made in connection with any claim on the
insurance Certificate/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 ***

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 CLAIMANT'S STATEMENT

8. What is your date of birth? (If married, please submit Marriage Contract.)
9. If you are filing 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 father/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

ACKNOWLEDGEMENT

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."

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 ATTENDING PHYSICIAN'S STATEMENT

(BEFORE ACCOMPLISHING THIS FORM, PLEASE READ INSTRUCTIONS AT THE BACK HEREOF)

This is in proof of my Medical Attendance to , under Certificate No.

, Master Policy No. insured by Etiqa Philippines.
I, , a graduate of
in the year , with residence address at ,
hereby truthfully and voluntarily state as follows:
1. (a) Full Name of Deceased (b) Residence at time of death

(c) From physical findings and appearances (d) What identifying marks have you noticed in the
what would you judge to be the age of body of the deceased?
the deceased?

2. (a) Do you know deceased personally? (b) How long have you known the deceased?

(c) How many times did you attend to (d) When was your first attendance?
deceased?
(e) What were deceased's complaints in (f) Who called you or accompanied the deceased
your first attendance? for treatment?

(g) Did you informed deceased of your diagnosis?

3. (a) Did you attend to deceased during last (b) If so, for what disease?
illness?
(c) What disease was the immediate (d) How long did deceased suffer from this
cause of death? disease?(give details)

(e) What were the first indications of (f) For how long before death was deceased
failing health? confined to house or prevented from attending
to business?
(g) Give date and hour when they were (h) For how long was deceased bedridden?
noticed by deceased.

4. (a) From what other disease, if any did (b) Give as nearly as you can the duration of each.
deceased suffer?

(c) Give below particulars of each condition for which you treated or advised deceased prior to last illness.
Disease/Illness Date Duration Result

(d) Give names and addresses of all other physician's and practitioners who, to your knowledge
attended to the deceased during the past three years.
Name Address Disease/Impairment & Date
__________________________
__________________________
__________________________

5. (a) Did you personally see the deceased?

(b) Date & Place of Death
(c) Was there an autopsy or other past post-mortem examination made on the body of the
deceased?

*** see back page ***

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 ATTENDING PHYSICIAN’S STATEMENT

6. Would you swear to the truth of the foregoing? .

Dated at this day of , .

PRINTED NAME AND SIGNATURE SIGNATURE OVER PRINTED NAME OF

OF WITNESS ATTENDING PHYSICIAN

Address of Witness Licensed Number

INSTRUCTIONS : ALL ANSWERS MUST BE ENTIRELY IN THE PHYSICIAN'S OWN HANDWRITING

The claimant is responsible for the submission of this Attending Physician's Statement which should be
accomplished by every physician who attended to the deceased during or before last illness.

If more than one physician attended to the deceased, each physician must accomplished the Attending
Physician's Form, which will be furnished by the Company upon claimant's request.

The physician who fills this form will facilitate the settlement of the claim by giving answer to pertinent
questions, a full statement of each pathological process, especially as to its duration, indefinite terms
terms are to be avoided unless full details are added.

If there was an autopsy made on the body of the deceased, a certified copy of the autopsy report should be
secured by the claimant and submit it along with this form.

Where the spaces provided for the answers are not enough, pertinent details may be given on, under
ADDITIONAL REMARKS.

ADDITIONAL REMARKS

The Company will be obliged if the Physician will use this space to furnish any additional
information not brought out in the foregoing statement.

Form No. GID-117

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
to present or use the same, or to allow it to be presented in support of any claim."

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 POLICYHOLDER'S STATEMENT
POLICYHOLDER: MASTER POLICY NUMBER :
NAME OF INSURED: CERTIFICATE NUMBER :
BEFORE FILLING UP THIS FORM, READ INSTRUCTIONS AT THE BOTTOM HEREOF, EVERY QUESTION MUST BE
DISTINCTLY AND FULLY ANSWERED.
1. Full Name of Deceased :
2. (a) Date of Birth : (b) Place of Birth :
3. (a) Amount of Insurance : (b) Effective Date :
4. (a) Date of Death : (b) Place of Death :
(c) Age at Death : (d) Cause of Death :
(e) Date of Interment : (f) Place of Interment :
5. (a) Occupation before Death : (b) Date Employed :
(c) Date Employment was terminated :
(d) Date on which deceased last worked full time :
6. TO BE ANSWERED IF POLICYHOLDER IS AN ASSOCIATION, UNION, TRUSTEE, CLUB., ETC.
(a) Date of Membership of the deceased :
(b) Was deceased in good standing at the time of death?
(c) Date Membership of deceased was terminated :
7. Date deceased first complained or showed symptoms of last illness :
8. Date deceased first consulted a physician for last illness:
9. (a) Was death due to / / Suicide / / Homicide / / Occupational Accident ?
(b) Describe fully the particulars as to the place it occurred and how it occurred :

10. Names and addresses of all physicians who attended the deceased during last illness and within the last
three years before the last illness preceding it and / or hospitals or other institution in which the deceased
was confined or received treatment within the last three years.
Name of Physician/ Address Date of Disease or
Hospital/Institution Attendance Condition

NAME OF BENEFICIARIES RELATIONSHIP ADDRESS

12. Do you recommend payment of this claim?

13. Remarks :

Dated at this day of 19 .

WITNESSED BY :

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

Position/Title

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 subscribes any writing with intent to present or use the same, or to allow it to be presented

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 IDENTIFYING WITNESS' STATEMENT

This Statement must be executed by a competent person who (a) is of legal age, (b) has personal
knowledge of the facts of the deceased's death; and (c) is not an interested party to the claim.

I, , a resident of

HEREBY CERTIFY that the answers to the following questions are true and correct to the best of my
knowledge and belief:

1. Full Name of the Deceased:

2. Date of Birth of the Deceased:
3. Residence of the deceased during your acquaintance:
4. Name of Employer/Union/Association and address:

5. Occupation(s) of the deceased during the last five (5) years prior to death:
6. Date of Death: Place of Death:
7. Cause of Death:
8. Did you view the body of the deceased after death?
9. Date of Interment: Place of Interment:
10. How long have you known the deceased?
11. Do you know the deceased to be the person insured in the Certificate/Policy of Insurance?
12. What is your age? What is your occupation?
13. How long have you resided at your present address?
14. Are you, in any way, related to the deceased?
15. Do you have, directly or indirectly any interest in the proceeds of any insurance on the life of
the deceased?

Dated this day of , .

WITNESSED BY:

Signature over Printed Name Signature of Identifying

Address Address

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 subscribes any writing with intent
to present or use the same, or to allow it to be presented in support of any claim."

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