FLH790a FLH790a

APPLICATION FOR APPLICATION FOR

INSURANCE CLAIMS INSURANCE CLAIMS

Please check purpose Please check purpose

Earthquake Flood Other Allied Perils Earthquake Flood Other Allied Perils
Fire Typhoon ______________ Fire Typhoon ______________
Date Filed: ___________ File No. ___________ Date Filed: ___________ File No. ___________
BORROWER’S DATA BORROWER’S DATA
Last Name First Name Name Ext. Middle Name Last Name First Name Name Ext. Middle Name

Maiden Name (For married women) Gender HL Account No. Maiden Name (For married women) Gender HL Account No.
Male Male
Female Female
Status Date of Birth Status Date of Birth
Single Widow/er Annulled Single Widow/er Annulled
Married Legally Separated Married Legally Separated
Company/Employer/Business Name Company/Employer/Business Name

Company/Employer/Business Address Tel. No. Company/Employer/Business Address Tel. No.

Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province) Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province)

Contact Nos. (Home/Mobile Number/Fax No.) Date of Occurrence Contact Nos. (Home/Mobile Number/Fax No.) Date of Occurrence

Borrower’s Borrower’s
Signature Signature

FOR BILLING AND COLLECTION DEPARTMENT/LCMRD FOR BILLING AND COLLECTION DEPARTMENT/LCMRD
Age Upon Age Upon
HL Account No. Co-Borrower(s) Loan Value HL Account No. Co-Borrower(s) Take-out
Loan Value
Take-out
1. 1.
2. 2.
3. 3.
4. 4.
Developer/Originating Bank Take-out Date Developer/Originating Bank Take-out Date

Program Program
FOLIO 1 CTS EHLP FOLIO 1 CTS EHLP
PI Express Lane (W1) UHLP/7B PI Express Lane (W1) UHLP/7B
OH Elite (W1) RL 9507 OH Elite (W1) RL 9507
Overhang Regular (W2) RL 8501 Overhang Regular (W2) RL 8501
Cir. 100 50M Others ______ Cir. 100 50M Others ______

Interest Rate Annual Premium Term Last Renewal Date Interest Rate Annual Premium Term Last Renewal Date

Verified by Date Certified by Date Verified by Date Certified by Date

Remarks Remarks Remarks Remarks

REQUIREMENTS: (3 copies each) REQUIREMENTS: (3 copies each)

1. Sworn Statement of Formal Claim 1. Sworn Statement of Formal Claim
2. Certification from the Barangay Captain 2. Certification from the Barangay Captain
3. Bill of Materials (Cost of Damage) (Duly signed by Engineer or 3. Bill of Materials (Cost of Damage) (Duly signed by Engineer or
Carpenter) Carpenter)
4. Pictures of the mortgaged/assigned property damaged by the 4. Pictures of the mortgaged/assigned property damaged by the
typhoon typhoon
5. Non-waiver Agreement 5. Non-waiver Agreement
* Additional requirements may be required for submission by the * Additional requirements may be required for submission by the
Insurance Pool. Insurance Pool.
(Revised/September 2009) (Revised/September 2009)