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HQP-HLF-421 Application for MRI or SRI Claims
Pag - Ibig claim application form for MRI/SRI
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HQP-HLF-421
APPLICATION FOR MRI/SRI CLAIMS
APPLICATION FOR MRI/SRI CLAIMS
_______________
Branch
_______________
Branch
Please check purpose:
Death
Please check purpose:
Permanent Total Disability (PTD)
Date Filed: ___________
Terminal Illness
File No. ___________
TO BE ACCOMPLISHED BY THE BENEFICIARY ONLY
Name of Borrower (Last Name, First Name, Name Ext., Middle Name)
Principal Borrower
Date of Birth
Death
Permanent Total Disability (PTD)
Date Filed: ___________
File No. ___________
TO BE ACCOMPLISHED BY THE BENEFICIARY ONLY
Name of Borrower (Last Name, First Name, Name Ext., Middle Name)
Principal Borrower
Age
Terminal Illness
Date of Birth
Age
Date of Death
Cause of Death
Co-Borrower
Co-Borrower
HL Account No.
Date of Death
Date of Terminal Illness / PTD
HL Account No.
Cause of Death
Date of Terminal Illness / PTD
Nature of Illness / PTD
Name of Beneficiary
Name of Beneficiary
Address of Beneficiary
Nature of Illness / PTD
Address of Beneficiary
Relationship to the Borrower
Contact Number/s.
Relationship to the Borrower
Contact Number/s.
Beneficiary’s
Signature
Beneficiary’s
Signature
THIS PORTION IS FOR Pag-IBIG FUND USE ONLY
HL Account
No.
Age Upon
Takeout
Co-Borrower/s
Loan Value
THIS PORTION IS FOR Pag-IBIG FUND USE ONLY
HL Account
No.
Age Upon
Takeout
Co-Borrower/s
1.
1.
2.
Loan Value
2.
Developer/Originating Bank
Takeout Date
Developer/Originating Bank
Takeout Date
Program
Program
FOLIO 1
PI
OH
Overhang
Cir. 100
CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M
EHLP
UHLP/7B
RL 9507
RL 8501
Others ______
FOLIO 1
PI
OH
Overhang
Cir. 100
CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M
EHLP
UHLP/7B
RL 9507
RL 8501
Others ______
Interest Rate
Annual Premium
Last Renewal Date
Loan Term
Interest Rate
Annual Premium
Last Renewal Date
Loan Term
Verified by
Date
Certified by
Date
Verified by
Date
Certified by
Date
Remarks
Remarks
Remarks
Remarks
REQUIREMENTS:
A. Permanent Total Disability/Terminal Illness
1. Attending physician’s statement of disability /Terminal illness
physician’s statement
2. Insured’s statement of disability/ illness
NOTE: Pro-forma of Item No. 1 and 2 are available at any Pag-IBIG
Fund offices.
3. Complete medical records
4. NSO Certified True Copy of Birth Certificate or Baptismal
5. If borrower is married, NSO Certified True Copy of Marriage Contract
REQUIREMENTS:
A. Permanent Total Disability/Terminal Illness
1. Attending physician’s statement of disability /Terminal illness
physician’s statement
2. Insured’s statement of disability /illness
NOTE: Pro-forma of Item No. 1 and 2 are available at any Pag-IBIG
Fund offices.
3. Complete medical records
4. NSO Certified True Copy of Birth Certificate or Baptismal
5. If borrower is married, NSO Certified True Copy of Marriage Contract
B. Death
Submit 1 original and 2 photocopies each
1. NSO Certified True Copy of Borrower’s Death Certificate
NOTE: Local Civil Registrar Certified True Copy (with stamped that it
was already endorsed to NSO) may be submitted only if the
date of filing is within 2 months from date of death.
2. NSO Certified True Copy of Birth Certificate or Baptismal
3. If borrower is single, Certificate of No Marriage (CENOMAR) and
NSO Certified True Copy of Marriage Contract of Parents
4. If borrower is married, NSO Certified True Copy of Marriage Contract
and Advisory of Marriage
5. Police Report (if death due to accident)
Submit 3 photocopies each
6. Notarized Proof of Surviving Legal Heirs
7. Notarized Affidavit of Guardianship (if with child/children below 18
years old, or if child/children is/are physically/mentally incompetent)
8. NSO Certified True Copy of Birth Certificate of all Children or
Baptismal (if with child/children) or Surviving Parents
9. NSO Certified True Copy of Marriage Contract of all Female Legal
Age Children (if with child/children)
10. NSO Certified True Copy of Death Certificate of Spouse (if borrower
is married) or Parents (if borrower is single)
11. Special Power of Attorney, if applicable
12. Complete Medical Records (for housing loan exceeded P 6M)
13. Certificate of Attending Physician
B. Death
Submit 1 original and 2 photocopies each
1. NSO Certified True Copy of Borrower’s Death Certificate
NOTE: Local Civil Registrar Certified True Copy (with stamped that it
was already endorsed to NSO) may be submitted only if the
date of filing is within 2 months from date of death.
2. NSO Certified True Copy of Birth Certificate or Baptismal
3. If borrower is single, Certificate of No Marriage (CENOMAR) and
NSO Certified True Copy of Marriage Contract of Parents
4. If borrower is married, NSO Certified True Copy of Marriage Contract
and Advisory of Marriage
5. Police Report (if death due to accident)
Submit 3 photocopies each
6. Notarized Proof of Surviving Legal Heirs
7. Notarized Affidavit of Guardianship (if with child/children below 18
years old, or if child/children is/are physically/mentally incompetent)
8. NSO Certified True Copy of Birth Certificate of all Children or
Baptismal (if with child/children) or Surviving Parents
9. NSO Certified True Copy of Marriage Contract of all Female Legal
Age Children (if with child/children)
10. NSO Certified True Copy of Death Certificate of Spouse (if borrower
is married) or Parents (if borrower is single)
11. Special Power of Attorney, if applicable
12. Complete Medical Records (for housing loan exceeded P 6M)
13. Certificate of Attending Physician
(V 01, 05/2015)
(V 01, 05/2015)
