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HQP-HLF-080

HQP-HLF-080

APPLICATION FOR
INSURANCE CLAIMS

APPLICATION FOR
INSURANCE CLAIMS

Please check purpose

Please check purpose

Earthquake
Fire

Flood
Typhoon

Other Allied Perils


______________

Date Filed: ___________

File No. ___________

Earthquake
Fire

Flood
Typhoon

Date Filed: ___________

BORROWERS DATA
Last Name

First Name

Name Ext.

Maiden Name (For married women)

Sex

File No. ___________

BORROWERS DATA
Middle Name

Last Name

First Name

HL Account No.

Maiden Name (For married women)

Name Ext.

Sex

Male
Female
Change in Marital Status
Married
Annulled

Middle Name

HL Account No.

Male
Female
Date of Birth

Single/Unmarried
Legally Separated

Other Allied Perils


______________

Widow/er

Change in Marital Status

Date of Birth

Single/Unmarried
Legally Separated

Company/Employer/Business Name

Married
Annulled

Widow/er

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.)

Contact Nos. (Home/Mobile Number/Fax No.)

Date of Occurrence

Borrowers
Signature

Borrowers
Signature

FOR BILLING AND COLLECTION DEPARTMENT/LCMRD


HL Account No.

Co-Borrower(s)

Age Upon
Take-out

Loan Value

FOR BILLING AND COLLECTION DEPARTMENT/LCMRD


HL Account No.

Co-Borrower(s)

1.

1.

2.

2.

3.

3.

Age Upon
Take-out

Loan Value

4.

4.

Developer/Originating Bank

Take-out Date

Developer/Originating Bank

Take-out Date

Program

Program
FOLIO 1
PI
OH
Overhang
Cir. 100

CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M

Interest Rate

Annual Premium

Verified by

Date

Remarks

Date of Occurrence

Term

Certified by

EHLP
UHLP/7B
RL 9507
RL 8501
Others ______

FOLIO 1
PI
OH
Overhang
Cir. 100

CTS
Express Lane (W1)
Elite (W1)
Regular (W2)
50M

Last Renewal Date

Interest Rate

Annual Premium

Date

Verified by

Date

Remarks

Remarks

Term

Certified by

EHLP
UHLP/7B
RL 9507
RL 8501
Others ______
Last Renewal Date

Date

Remarks

REQUIREMENTS: (3 copies each)

REQUIREMENTS: (3 copies each)

1. Cost of damages/bill of materials; in case of total loss of property, it


must be duly signed by a licensed architect or civil engineer
2. Photos of the damaged property
3. Formal Claim
4. Non-Waiver Agreement
* Additional requirements may be required for submission by the
Insurance Pool.

1. Cost of damages/bill of materials; in case of total loss of property, it


must be duly signed by a licensed architect or civil engineer
2. Photos of the damaged property
3. Formal Claim
4. Non-Waiver Agreement
* Additional requirements may be required for submission by the
Insurance Pool.

(April 2012)

(April 2012)

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