claimant statement

LAC 2 (032013)

CLAIMANT’S STATEMENT DEATH CLAIM

Life Insured’s Information
Life Insured’s Name:
SAN MIGUEL ARTEMIO SR. LAVARIAS.
__
Last Name First Name Middle Name

b. Address:
TAMBACAN, BRGY. POBLACION, STA. CATALINA NEG. OR.

c. Date of Birth: 04DEC1951 Place of Birth: ZAMBOANGA CITY

Nationality FILIPINO Age: 66 Status: MARRIED
d. Occupation: FIREMAN Name of Employer: BUREAU OF FIRE PROTECTION
Address: POBLAION, STA. CATALINA, NEG. OR
e. Date of Death: JANUARY 2, 2018 Place of Death:
Bayawan District Hospital
f. Cause of Death:
CARDIAC ARREST

g. Please state the name and address of all Physicians including medical institutions where life insured had
record of consultation/s and confinement/s:

Date of
Attendance
Name of Physician/Address Medical Institution/Address Diagnosis/Treatment/Procedure
h. Other life and accident insurance on the life of the insured:
Insurance Company Date of Policy Amount of Insurance

2) Claimant’s Information
a. Claimant’s Name:
SAN MIGUEL, CONCHITA NUIQUE

Last Name First Name Middle Name

b. Address:
TAMBACAN, BRGY. POBLACION, STA. CATALINA, NEG. OR.

C Date of Birth: 20AUG1954 Place of Birth: GILIGAON, SIATON, NEG. OR.

Nationality: FILIPINO Age: 68 Status: WIDOW
d. Contact Details: Home: 0916994525 Office: N.A. Cell Phone 09169945525
Fax: N.A. Email address: NONE
e. Relation to the Life Insured WIFE
CLAIMANT’S DECLARATION AND AUTHORIZATION
In my capacity as beneficiary of the Policy (o trustee of the minor beneficiary) , I hereby authorize any
physician medical practitioner, hospital, clinic, other medical or medically related facility, insurance or
reinsuring company, the Medical Information Bureau, Inc., consumer reporting agency, entity or employer,
having information as to diagnosis, treatment, results and prognosis, with respect to the physical or mental
examination or condition of the insured
 claimant statement

to give to GENERALI PILIPINAS LIFE ASSURANCE COMPANY,

INC., (GPLAC) or its legal representative, any and all information, or any other information or record it may
need to process the claim on the deceased life insured.
The authority herein given pertains to all records containing medical or non-medical data including, but not
limited to, medical and dental care, drug or alcohol use, prescribed drugs, information about communicable
diseases, and any employment and insurance coverage information.
I also authorize GPLAC to obtain an investigative report from its duly authorized inspection agency which will
provide any applicable information concerning this claim for insurance benefits on the life of the insured

I agree that a photographic copy of this Authorization shall be valid as the Original.
This authorization discharges Generali Pilipinas Life Assurance Company or any of its authorized
representative from any responsibility or obligation in connection with the release of such record or information.
As described above and for that purpose, I attest that the foregoing answers are true and correct and complete
to the best of my knowledge and belief.
Dated at Dumaguete City this day of

Signature Over Printed Name Of Witness Signature Over Printed Name of Claimant
SUBSCRIBED AND SWORN to me this ______ day of ____________________, 20_________ by the above
claimant who exhibited to me his/her Residence Certificate No. _________________________ issued at
__________________________ on ________________________________.

Doc No. Book No.

Page No. Series of

My Commission expires on
Gercon Plaza Building, 7901 Makati Avenue, Makati City, 1227 Philippines
(632) 885-4100 | Fax (632) 752-6892 | TIN 203-028-350-000
E-mail: info@generali.com.ph | Website: www.generali.com.ph

CLAIMANT’S STATEMENT DEATH CLAIM

1) Life Insured’s Information
a. Insured’s Name:
SAN MIGUEL ARTEMIO SR. LAVARIAS.
__
Last Name First Name Middle Name

b. Address:
TAMBACAN, BRGY. POBLACION, STA. CATALINA NEG. OR.

c. Date of Birth: 02JAN2018 Place of Birth: ZAMBOANGA CITY

Nationality FILIPINO Age: 66 Status: MARRIED
d. Occupation: FIREMAN Name of Employer: BUREAU OF FIRE PROTECTION
Address: POBLAION, STA. CATALINA, NEG. OR
e. Date of Death: 02 JANUARY 2018 Place of Death:
 claimant statement
This authorization discharges Generali Pilipinas Life Assurance Company or any of its authorized
representative from any responsibility or obligation in connection with the release of such record or information.
As described above and for that purpose, I attest that the foregoing answers are true and correct and complete
to the best of my knowledge and belief.
Dated at Dumaguete City this day of

Signature Over Printed Name Of Witness Signature Over Printed Name of Claimant
SUBSCRIBED AND SWORN to me this ______ day of ____________________, 20_________ by the above
claimant who exhibited to me his/her Residence Certificate No. _________________________ issued at
__________________________ on ________________________________.

Doc No. Book No.

Page No. Series of

My Commission expires on
Gercon Plaza Building, 7901 Makati Avenue, Makati City, 1227 Philippines
(632) 885-4100 | Fax (632) 752-6892 | TIN 203-028-350-000
E-mail: info@generali.com.ph | Website: www.generali.com.ph
 Attending physician statement

eceased
Please enclose copies of specialist or hospital reports together with any tests
or similar evidence to support the validity of the claim.
I hereby certify that the above statements are true and complete to the best of my knowledge and belief.
Dated at this __________day of
20_____.

Address contact details

SUBSCRIBED AND SWORN to me this ______ day of ____________________, 20_________ by the above
claimant who exhibited to me his/her Residence Certificate No. _________________________ issued at
__________________________ on ________________________________.

Doc No. Book No.

Page No. Series of

My Commission expires on
Gercon Plaza Building, 7901 Makati Avenue, Makati City, 1227 Philippines
(632) 885-4100 | Fax (632) 752-6892 | TIN 203-028-350-000
E-mail: info@generali.com.ph | Website: www.generali.com.ph
ATTENDING PHYSICIAN’S STATEMENT – DEATH CLAIM
Note: Kindly submit this form to Generali Pilipinas Assurance Company, Inc.,
(GPLAC) duly completed by a qualified and registered physician.
1. PATIENT’S DETAILS
a. Deceased’s Name :
SAN MIGUEL, ARTEMIO SR. LAVARIAS
Last Name First Name Middle Name
b. Address:
TAMBACAN, BRGY. POBLACION, STA. CATALINA NEG. OR.

c. Date of Birth: 04DEC1951 Place of Birth: ZAMBOANGA CITY

Age: 66 Status: MARRIED
d. Date of Death: 02 JANUARY 2018 Place of Death:

e. Cause of Death :
Immediate Cause
SUDDEN CARDIAC ARREST
Antecedent case

Underlying Cause

Other significant factors contributing to

death
f. How long has the deceased been your
patient?
g. If you attended to the deceased during the last illness, please answer the
following questions:
g.1 Date of first consultation Diagnosis
 attending physician statement

g.2 Initial signs and symptoms noticed by the deceased

g.3 Duration of the disease or illness and inclusive date/s of treatment

h. Did you personally inform the deceased of your findings and diagnosis? If so,
when?
i. Please give details of the deceased’s previous health conditions to which you
attended prior to last illness :
Date of Attendance Diagnosis Treatment/Procedure
j. How long before death was the deceased confined to house or prevented from
attending to business or occupation?
How long was the deceased
bedridden?
k. Are you aware of any other consultation or confinement of the deceased for any
illness or injury? If so, please provide
information below:
Date of
Attendance
Name of Physician/Address Medical Institution/Address
Diagnosis/Treatment/Procedure
l. Did you personally see the remains of the deceased?
m. Was there an autopsy or any other post-mortem examination made on the body of
the deceased?
Please enclose copies of specialist or hospital reports together with any tests
or similar evidence to support the validity of the claim.
I hereby certify that the above statements are true and complete to the best of
my knowledge and belief.
Dated at this __________day of
20_____.

Signature Over Printed Name of Physician Qualification

Address Contact Details

SUBSCRIBED AND SWORN to me this ______ day of ____________________, 20_________ by the above
claimant who exhibited to me his/her Residence Certificate No. _________________________ issued at
__________________________ on ________________________________.

Doc No. Book No.

Page No. Series of

My Commission expires on
Gercon Plaza Building, 7901 Makati Avenue, Makati City, 1227 Philippines
(632) 885-4100 | Fax (632) 752-6892 | TIN 203-028-350-000
E-mail: info@generali.com.ph | Website: www.generali.com.ph