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Formal Claim

Pag - Ibig formal claim for MRI/SRI application claims

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To: ___________________________

Date: ________________________

This is to serve formal notice of damage/loss of property _________________the
particulars of which are as follows:

1. Date and hour of damage/loss.
2. Location of property damaged or lost.
3. How and by whom were premises occupied
at date of damage/loss?
4. What was the cause of damage/loss and
under what circumstances did it occur?
5. Is Claimant the sole owner of the property
damaged/lost? (If not, state full details of any
other interest.)
6. Did you remove or save any belongings
immediately before or during occurrence? If
so, how much is the estimated cost of such
and where are they located now?
7. Do you have similar property at any other
location? If so, where is it located and how
much is the insurance coverage, if any?
8. Has there been previous loss in this
premises or in any other premises in which
you are interested as the Insured? If so, state
full details including the cause of such loss.
9. Value of the Insured Property at the time of
loss per attached inventory and/or estimate.
10. Statement of other Insurance coverage in force upon the property destroyed or lost.
Name of Company

Policy No.

Amount

I/We ______________________of _______________do hereby declare that the
above statements are true and accurate, and I/We further declare that my/our property,
worth P ___________________according to the extent and value annexed and insured
was accidentally damaged and/lost, as stated above without any design or procurement
on my/our part. Wherefore, I/We claim from my/our insurer/s the sum of
__________________________________________ (P____________________).
I/We further declare that the attached documents and/or records are being
submitted as proof of my/our claim on my/our loss. I/We further agree that any action to
be done by my/our insurers or their representatives in connection with the abovedescribed loss or other matters relative thereto shall not waive, invalidate, forfeit or

modify any of their rights under the terms and conditions of the insurance policy and
that this agreement on my part is to assist, and for the convenience of my/our insurer’s
representative to be allowed investigation on the claim and ascertain that appropriate
values of damage/loss to the property involved be made without any delay and without
prejudice to any of their rights.

_____________________________
Insured
______(ID)______ No. ___________

Date of Issue __________________
Expiry Date __________________
Place of Issue _________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )
City of ______________________) S.S.

BEFORE ME, A Notary Public for and in the City of ________________, this
_____
day
of
____________,
20____
personally
appeared
Mr./Ms.
_______________________, and who has satisfactorily proven to me his/her identity
through his/her I.D. No. ____________ valid until __________ that he/she is the same
person who executed and voluntarily signed the foregoing Formal Claim, which he/she
acknowledged before me as his/her free and voluntary act and deed.
The foregoing Formal Claim consisting of ______(_) pages including the page on
which this acknowledgment is written, has been signed on the left margin of each and
every page by the insured.
WITNESS MY HAND AND NOTARIAL SEAL on the date and place above
written.

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of _______.
 
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