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03182014a-AFB Application for Funeral Benefit

GSIS application form for funeral benefits

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Form No. 03182014a-AFB

APPLICATION FOR FUNERAL BENEFIT
(Please Read Terms and Conditions and Documentary Requirements at the back)
INSTRUCTIONS: Ensure that the application form is properly filled out and submit duly accomplished application form to the
nearest GSIS/Handling Office.
WARNING: Direct or indirect commission of fraud, collusion, falsification, misrepresentation of facts, or any other kind of anomaly in
the accomplishment of this form, or in obtaining any benefit under this application shall be subject to administrative, civil and/or
criminal action.
Must be received by GSIS within four (4) years from the date of death of deceased member/pensioner together with the required
supporting documents.
DATE OF FILING OF APPLICATION_________________________
A.DECEASED MEMBER/RETIREEE/PENSIONER:
Last Name

DATE OF DEATH OF MEMBER __________________________

First Name

Middle Name

Name/Address of Last Government Office
Date of Birth (mm/dd/yyyy)

GSIS Business Partner (BP) No.
Gender

Religion
Male

Civil Status
Married

Single

Separated

Female
Status at the time of death
Active Member
Retiree

Widow/Widower

B. PRIMARY BENEFICIARY (LEGAL SPOUSE), If living:
Last Name
First Name

Pensioner

Middle Name

Mailing Address (No/Street/Barangay/Municipality/City/Province/Zip Code)

BP No. (if applicable)

Date of Birth (mm/dd/yyyy)

Religion

Date of Marriage (mm/dd/yyyy)

Contact No. (Landline)

Cellphone No.

E-mail Address

C. CLAIMANT IS OTHER THAN SPOUSE
Last Name

First Name

Middle Name

Mailing Address (No/Street/Barangay/Municipality/City/Province/Zip Code)
Date of Birth (mm/dd/yyyy)

Relationship

Cellphone No.

BP No. (if applicable)
Email Address

I hereby certify that the foregoing information are true and correct and the attached documents are authentic.
Witnesses to thumbmark:

1. _____________________________
________________________________________________

Signature of Applicant over Printed Name

Right Thumbmark
(if unable to affix signature)

2. _____________________________

Claim proceeds shall be electronically credited to your eCard/UMID account and may be withdrawn from your nearest ATM. If
you have no eCard/UMID, the proceeds will be paid through check.

Application Received By:
Date Received:
TMS Reference No.:

TERMS AND CONDITIONS
1. Funeral benefit is intended to help defray the expenses incident to the burial and funeral of the
deceased member, pensioner or retiree under RA 660, RA 1616, PD 1146 and RA 8291. It is payable to
any qualified individual, in accordance with the following order of priority:
a. Legitimate spouse,
b. Legitimate child who spent for the funeral services, or
c. Any other person who can show incontrovertible proof that he shouldered the funeral expenses
of the deceased
2. Amount of Funeral Benefit. The amount of funeral benefit are as follows:
a. The prevailing amount approved by the Board of Trustees at the time of death of the member or
pensioner.
b. For uniformed members of the PNP, BJMP and BFP, the amount of funeral benefit is fixed at
P10,000.00.
3. Conditions for Entitlement.- Funeral benefit shall be paid upon the death of:
a. an active member; or
b. a member who has been separated from the service with more than 15 years of creditable
service, but entitled to future separation or retirement benefits; or
c. old age or disability pensioner; or
d. a retiree who at the time of his retirement is at least 60 years of age and with at least 20 years of
service but who opts to retire under RA 1616 on or after June 24, 1997; or
e. a member who retired under RA 1616 prior to June 24, 1997 with at least twenty (20) years of
service, regardless of age.

DOCUMENTARY REQUIREMENTS

A. CLAIMANT IS THE SPOUSE
1. Duly accomplished Application Form for Funeral Benefit
2. Death Certificate of member issued by Local Civil Registrar (LCR) or National Statistics Office
(NSO)
3. Marriage Contract of member with the surviving spouse issued by LCR OR NSO
4. If surviving spouse is not a GSIS member, Birth Certificate issued by NSO or LCR, OR two
valid government issued IDs with date of birth and signature
B. CLAIMANT IS OTHER THAN THE SPOUSE
1. Duly accomplished Application Form for Funeral Benefit
2. Death Certificate of member issued by LCR OR NSO
3. If claimant is not a GSIS member, Birth Certificate issued by LCR or NSO or two valid
government issued IDs with date of birth and signature
4. Death Certificate of legal spouse issued by LCR OR NSO if married
5. If legal spouse is living, notarized waiver in favor of the claimant with two (2) valid IDs of the
legal spouse with signature
6. Official receipt of funeral expenses issued in the name of the claimant
 
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