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HQP-HLF-080 Application for Insurance Claim
Pag - Ibig application form for insurance claim
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HQP-HLF-080
APPLICATION FOR
INSURANCE CLAIMS
APPLICATION FOR
INSURANCE CLAIMS
Please check purpose
Please check purpose
Earthquake
Fire
Flood
Typhoon
Other Allied Perils
______________
Date Filed: ___________
File No. ___________
Earthquake
Fire
Flood
Typhoon
Date Filed: ___________
BORROWER’S DATA
Last Name
First Name
Name Ext.
Maiden Name (For married women)
File No. ___________
BORROWER’S DATA
Middle Name
Last Name
HL Account No.
Sex
First Name
Name Ext.
Maiden Name (For married women)
Sex
Male
Female
Change in Marital Status
Married
Annulled
Middle Name
HL Account No.
Male
Female
Date of Birth
Single/Unmarried
Legally Separated
Other Allied Perils
______________
Widow/er
Change in Marital Status
Date of Birth
Single/Unmarried
Legally Separated
Company/Employer/Business Name
Married
Annulled
Widow/er
Company/Employer/Business Name
Company/Employer/Business Address
Tel. No.
Company/Employer/Business Address
Tel. No.
Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province)
Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province)
Contact Nos. (Home/Mobile Number/Fax No.)
Contact Nos. (Home/Mobile Number/Fax No.)
Date of Occurrence
Borrower’s
Signature
Borrower’s
Signature
FOR BILLING AND COLLECTION DEPARTMENT/LCMRD
HL Account No.
Co-Borrower(s)
Age Upon
Take-out
Loan Value
FOR BILLING AND COLLECTION DEPARTMENT/LCMRD
HL Account No.
Co-Borrower(s)
1.
Loan Value
2.
3.
Age Upon
Take-out
1.
2.
3.
4.
4.
Developer/Originating Bank
Take-out Date
Developer/Originating Bank
Take-out Date
Program
Program
FOLIO 1
PI
OH
Overhang
Cir. 100
CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M
Interest Rate
Annual Premium
Verified by
Date
Remarks
Date of Occurrence
Term
Certified by
EHLP
UHLP/7B
RL 9507
RL 8501
Others ______
FOLIO 1
PI
OH
Overhang
Cir. 100
CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M
Last Renewal Date
Interest Rate
Annual Premium
Date
Verified by
Date
Remarks
Remarks
Term
Certified by
EHLP
UHLP/7B
RL 9507
RL 8501
Others ______
Last Renewal Date
Date
Remarks
REQUIREMENTS: (3 copies each)
REQUIREMENTS: (3 copies each)
1. Cost of damages/bill of materials; in case of total loss of property, it
must be duly signed by a licensed architect or civil engineer
2. Photos of the damaged property
3. Formal Claim
4. Non-Waiver Agreement
* Additional requirements may be required for submission by the
Insurance Pool.
1. Cost of damages/bill of materials; in case of total loss of property, it
must be duly signed by a licensed architect or civil engineer
2. Photos of the damaged property
3. Formal Claim
4. Non-Waiver Agreement
* Additional requirements may be required for submission by the
Insurance Pool.
(April 2012)
(April 2012)
