CLAIMANT’S STATEMENT (DEATH)

To: BPI-Philam Life Assurance Corp.

I hereby claim the benefit due the undersigned under Policy No. / s___________________________ and stated that the following answers are
true and correct according to my personal knowledge and belief.
I understand that the furnishing of this form and other claim forms do not necessarily mean that the Company is admitting liability under the

1 (a) Full name of the deceased: 6 (a) What is your date of birth?
(If you are an emancipated minor, please submit marriage
contract)
(b) Residence of the deceased:
(b) Please state your relationshp to the deceased:
(c ) Occupation of the deceased:
(c ) Are you the designated beneficiary? If answer is NO,
2 (a) Birthdate & Birth place: please state in what capacity you are filing this claim?

3 (b) Place of Death: (d) If you are filing this claim in behalf of minor beneficiaries, please

give their names & dates of birth & your relationship to them
(c ) Cause of Death below:
Minor's Birth
(d) Date & Place of Internment: Name Date
_________________________ ___________
4 (a) Date the deceased first complained of last illness: _________________________ ___________
_________________________ ___________
(b) Name & Address of physicians who attended to the deceased: _________________________ ___________
_________________________ ___________
_________________________ ___________

(c ) Names and address of medical institutions or hospitals where the (e) As father / mother of said minor/s, have you been disqualified by a
deceased was confined: court of law from exercising the right to administer the property
of such minor/s?

5 If deceased was insured with other companies, please state: YES ( ) NO ( )

Name of Co. Policy No.
__________________________ ____________ Is / are the same minor/s under your actual custody & support?
__________________________ ____________
__________________________ ____________ YES ( ) NO ( )

Dated at ______ this ________ day of ________________, 20_____.

_________________________________ ___________
WITNESS NAME & SIGNATURE OF CLAIMANT Tel. No.

ADDRESS OF WITNESS ADDRESS OF CLAIMANT

SUBSCRIBED AND SWORN to before me this _____ day of _________________, 20_______, by the above claimed who exhibited to me his /
her Residence Certificate No. ____________________ issued at ______________________ on _______.

NOTARY PUBLIC
Doc. No. __________________ Until Dec. 31, 20 _______
Page. No. __________________ PTR No. _____________
Book No. __________________ Issued on ____________
Series of 20______ At __________________

CLAIMANT'S AUTHORIZATION
TO WHOM IT MAY CONCERN:
Date
I hereby authroize the Ayala Life Assurance Incorporated or its represaentatives to secure whatever medical and personal information or records
of _______________________________________. This authorization is being made in connection with any claim on the insurance policy issued by
said company on the life of the incured / deceased.
This authorizartion discharges you or any authorized member of your staff from any responsibility or obligation in connection with the release of
such record or information.

Witness Name & Signature of Claimant

QR-BPLC-CSD / Rev 0 / May 2010 BPI-PHILAM Customer Confidential