Claimant's Statement Form

Caritas Corporate Centre, # 97 E. Rodriguez Sr. Blvd.
, Quezon
Tel No. 8635-7122 / email address : mbasadon@caritaslife.com.ph
CLAIMANT’S STATEMENT
The employment of a third person, on commission or otherwise, for the collection of an approved claim is unnecessary. Settlement is achieved most speedily by direct
communication with local representative of the Company.
PART I – ASSURED/DECEASED INFORMATION

FIRST NAME MIDDLE NAME LAST NAME
1 NAME IN FULL OF ASSURED
Place Country
Residence at the policy was issued.
2 Residence at time of death. Place Country
Where required by law, a government succession duly
release will have to be furnished.
Occupation at time policy was issued Occupation at time of death
3
Place and Date of Birth. Place of Birth Date of Birth

If age has not been admitted by the company, evidence Day Month Year
4
satisfactory establishing date of birth should by
produced.
Place of Death Date of Death
5 Place and Date of Death. Day Month Year
State all the facts regarding the cause and

circumstances of death. If an inquest was held, the
6
Coroner’s report must be furnished (Press clippings
should be attached hereto).
Give the date of first indication of failing
7 How long was the assured ill?
health.
Had the assured any illness previously. If so, give
8
details.
Did the assured use intoxicating liquors?
Did the assured use them to excess?
9
How long before death did the assured use them to
excess?
Name(s) Address(es)
Give the names and addresses of all physician’s
10
consulted by the assured within the last five years
Had the assured any other life assurance? If so, state

11
the companies and dates of the policies.
Did the assured ever claim any total disability, sickness
12 or accident benefits under any insurance contract
within the last five years. If so, give full details.
In what capacity or by what title do you claim the
amount due under the policy? If executor, Are you of the full age YES
13 14
administrator or guardian, certified copy of of majority
NO
appointment must be furnished.
Claimant’s Signature Date Signed
PART II – CLAIMANT’S INFORMATION
I HEREBY NOTIFY THE CARITAS LIFE INSURANCE COMPANY that ………………………………………………….
whose life was assured by the said company under Policy No. ………………………………….………… is dead ; and I hereby declare
that the said person is the one described above and that the foregoing answers and statements made by me are true and
correct. I hereby agree that the written statements and affidavits of all the physician's who attended or treated the
assured, and all other papers called for by the said company, shall constitute and they are hereby made a part of these
Proofs of Death , and further, I agree that the furnishing of this form , or any forms supplemental thereto, by said Company
shall not constitute nor be considered an admission by it that there was any assurance in force on the life in question, nor
a waiver of any of its rights or defense.
I expressly waive all provisions of law forbidding any physician or other person who has therefore
attended or examined the deceased, or any institution in which the deceased received treatment, from disclosing any
knowledge or information which was there-by acquired, and I authorize all such persons or agencies or government offices
to furnish any information in their possession to the said Caritas Life Insurance Corporation.
" Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount
claimed/or imprisonment of two (2) years, or both, at the discretion of the court, to any person who
presents or causes to be presented any fraudulent claim for the payment of a loss under a contract
of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to
present or use the same, or to allow it to be presented in support of any claim"
By signing below, I agree to supply the personal information, as provided above, for the purpose of processing my application for an insurance claim.
I understand that my personal information collected will be stored in Caritas Group of Companies owned buildings and Data Centers up to the duration
of the claim processing or until settlement. I acknowledge that CARITAS LIFE INSURANCE CORPORATION is committed to protect this information
with state of the art technology and processes and does not share this information to any third party other than stated below. As Data Owner/Subject,
I understand that I have the rights to access, to be informed, to object, to erasure or blocking, to rectify, to damages to data portability and rights to
file complaint.
Signed at : ____________________________________ this_______ day of_______________________________20______
Claimant’s Signature Date Of Birth (Month/Day/Year) Gender
Printed Name (Last Name, First Name, M.I.) Place Of Birth Nationality / Citizenship
Residence Address Zip Code
Place of Signing Date of Signing (Month/Day/Year)
Relationship to the Insured Home Phone / Fax / Mobile Phone Email Address
WITNESS :
Signature of Witness Printed Name (Last Name, First Name, M.I.)
Residence Address
Place of Signing Date of Signing (Month/Day/Year) Home Phone / Fax / Mobile Phone
CLICClaimsForm No. 0001/Revised 2020

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Caritas Corporate Centre, # 97 E. Rodriguez Sr. Blvd.

PART I – ASSURED/DECEASED INFORMATION

Place and Date of Birth. Place of Birth Date of Birth

State all the facts regarding the cause and

Had the assured any other life assurance? If so, state

Signed at : ________________________________ this_ day of_______________________20

Claimant’s Signature Date Of Birth (Month/Day/Year) Gender

Residence Address Zip Code

Place of Signing Date of Signing (Month/Day/Year)

CLICClaimsForm No. 0001/Revised 2020

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