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CLAIMANT'S STATEMENT
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| To: The Insular Life Assurance Company, Ltd. |
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| I
hereby claim for benefit the policy/policies of this Company,
numbered as follows: ________________________ All of the following
answers and statements are true, complete & correct according to
my personal knowledge & belief. |
| I
understand that the furnishing of this form and other claim forms by
the Company does not constitute an admission that there is any
insurance in force. |
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| 1. (a) Full name of deceased: |
5. If deceased was insured with other companies, please
states the following:NAME OF COMPANY POLICY NO. AMOUNT OF
INSURANCE |
| (b) Residence of
deceased: |
| (c) Occupation: |
| 2.
(a) Birthdate and Birthplace of deceased |
6.
(a) What is you date of birth? If a married minor, please
submit marriage certificate: |
| 3. (a) Date
of Death: |
(b) Please
state your relationship to the deceased such as son, daughter,
father, mother, etc. |
| (b) Place of Death: |
(c) Are you a
designated beneficiary? If answer is NO please state in what
capacity you are filling this claim? |
| (c) Cause of Death: |
(d) If you are filling this claim in behalf of
minor beneficiaries, please give their names and dates of
birth and your relation to them below: (State such as father,
mother, grandfather, stepfather, etc.)
NAME OF
MINORS BIRTH
DATE
YOUR RELATION
__________________________________________
__________________________________________
__________________________________________ |
| (d) Date and Place of
Interment: |
| 4.
(a) Date the deceased first complained of last illness. Give
indications. |
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(a) Names and addresses of all physicians who
attended the deceased.
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(e) 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
Is/Are the same minor/s under
your actual custody and support?
(a)
Names and addresses of all medical institutions or hospitals
where deceased was confined. | |
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(USE REVERSE SIDE FOR ADDITIONAL INFORMATION) |
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| Dated____________ this _______________ day of ______________,
19 ______ |
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______________________________
WITNESS |
____________________________________
ME AND SIGNATURE OF CLAIMANT |
______________________________
ADDRESS OF WITNESS |
____________________________________
ADDRESS OF CLAIMANT |
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| SUBSCRIBED AND SWORN to before me this _______________day of
_______________, 19 _____, by the above claimant who exhibited to me
his/her Residence Certificate No. A ____________________________,
issued at _______________ on |
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| Doc. No. _________ Book No. ________ |
NOTARY PUBLIC |
| Page No. _________ Series of 19 ________ |
My commission expires on _______________ |
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|
CLAIMANT'S AUTHORIZATION |
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| To Whom It May Concern; |
| This
authorizes the Insular Life Assurance Co., Ltd. or its authorized
representative to secure whatever information of record you may have
regarding the disease or injury for which the deceased, has been
treated or examined. This authorization is being made in connection
with any claim on the insurance policy issued by said insurance
company on the life of the deceased. |
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| This
authorization discharges you or any authorized member of your staff
from any responsibility or obligation in connection with the release
of such record or information. |
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| Signed at ______________this ___________ day of____________,
19_____ |
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___________________________
WITNESS |
____________________________________
NAME AND SIGNATURE OF CLAIMANT |
___________________________
ADDRESS OF WITNESS |
____________________________________
ADDRESS OF CLAIMANT
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(Print Form)