Ve, . ASIA UNITED INSURANCE, INC, 15™ Floor, BDO Dasmarifias Tower oo Dasmarifias cor. Marquina Sts. Binondo, Manila Tel. 242-1688 Fax 245-3255 u Ic c 1. Completely accomplish the Accident Claim Report Form below. 2. _Askattending Physician to accomplish the Attending Physician's Report form. 3. Attach necessary documents (see check list below) 4, Forward the Claim Report and other necessary documents to ASIA UNITED INSURANCE, INC. DOCUMENTARY REQUIREMENTS ‘A. Accidental Death Claim B._ Medical Reimbursement (() Original Attending Physician's Report (() Original Attending Physician’s Report (_) Original Police Investigation Report () Certification from Schoo! Principal (_) Certified True Copy of Birth Certificate (_.) Certification from Company's HR Department () Certified True Copy of Death Certificate () Original Medical Bills and Receipts (_) Certified True Copy of Marriage Contract () Original Medical Certificate (_) Original Autopsy Repor (if applicable) (.). Original Hospital Statement of Account (_.) Original Burial Expense Receipts () Policy Report (if applicable) (_.) Certification from School Principal (.) Pictures showing the injury sustained (_) IDs: (Company, Driver's license, Schoo!) (_) IDs: (Company, Driver's license, School) ACCIDENT CLAIM REPORT (TO BE ACCOMPLISHED BY THE PRINCIPAL INSURED OR BENEFICIARY) Principal insured: Policy No. Claimants Name: Beneficiary adress: Person Accomplishing this Report: Contact Number Relation to Vietin: ‘A_ Brief Description of Accident (Maiking salaysay ng aksidente) 'B._Date, Time and Place of Accident (ATaw, Oras af Lugar kung saan nangyani ang aksidente) ‘© What was the injured person doing when the accident happened? (Ano ang ginagawa niya bago nangyari ang aksidente?) AUTHORIZATION | HEREBY AUTHORIZE any hospital physician, or other person who altended or examined me / the victim, to fumish to the ‘Company, or its representative, any and all information with respect to any illness. or injury, medical history, consultation prescription or treatment and copies of all hospital or medical records. A Photostat (xerox) copy of this authorization shall be ‘considered as effective and valid as the original Place ‘Signature of Claimant