LUCENA CITY PUBLIC SCHOOL TEACHERS AND EMPLOYEES ASSOCIATION

NAME OF MEMBER 1.)

( Last Name) (First Name) ( Middle Name)

2) 3.

BIRTHDAY ( MM-DD-YYYY) AGE & STATUS ( SINGLE/ MARRIED/WIDOW)

4.)

DISTRICT / COMPLETE NAME OF SCHOOL

5.)

COMPLETE HOME ADDRESS

6.) 7.)

CELLPHONE NUMBER/LANDLINE CONTACT NO. EMAIL ADDRESS

8. Kindly check on the category of claim for:

Members’ Death Claim Beneficiary Retiree

Date of Death: Date of Death: Date of Retirement:

Cause of Death: Relationship to the Member: Years of Membership:

9.) CERTIFICATION ( for members with updated payment)

This is to certify that ________________________________, teacher/employee at ______________________________

and is eligible to claim the stated benefits above in the association. This also certifies that he/she is updated with the
mutual aid contribution from the date of his/her membership up to present.

SCHOOL TREASURER SCHOOL FACULTY PRESIDENT PRINCIPAL

Signature over Printed Name Signature over Printed Name Signature over Printed Name

10.) CERTIFICATION ( for members with UNSETTLED payment)

This is to certify that ________________________________, teacher/employee at ______________________________

He/she needs to update his/her contribution of P ____________________. This is also to certify that the said member is

aware that his/her unsettled contributions will be deducted from the amount she is applying for the specific claim.

SCHOOL TREASURER SCHOOL FACULTY PRESIDENT PRINCIPAL

Signature over Printed Name Signature over Printed Name Signature over Printed Name

MEMBER/CLAIMANT DISTRICT TREASURER DISTRICT PRESIDENT

Signature over Printed Name Signature over Printed Name Signature over Printed Name
11.) CERTIFICATION ( HEALTH AID BENEFITS: Please attached Medical Certificate )

This is to certify that ________________________________, teacher/employee at ______________________________

is presently under the treatment/medication of : ( Kindly check the specific case)

CANCER

MAJOR OPERATION ( Excluding Caesarian Operation) Specify ______________________________

DIALYSIS

CHEMO THERAPHY

TRANSPLANT

STROKE

MEMBER/CLAIMANT DISTRICT TREASURER DISTRICT PRESIDENT

Signature over Printed Name Signature over Printed Name Signature over Printed Name

SHERLYN P. PEÑAFLOR WENDELL L. PEREZ

ATTENDING PHYSICIAN LCPSTEA TREASURER LCPSTEA PRESIDENT
Signature over Printed Name Signature over Printed Name Signature over Printed Name
---------------------------------------------------------------------------------------------------------------------------------------------------------

FOR FINAL APPROVAL & RELEASING

CHECKED & VERIFIED: DATE:

SHERLYN P. PEÑAFLOR LILIA B. RAGAS WENDELL L. PEREZ

LCPSTEA TREASURER LCPSTEA AUDITOR LCPSTEA PRESIDENT
Signature over Printed Name Signature over Printed Name Signature over Printed Name

Type of Claim : _____________________________________

Amount of Aid:____________________________________

Unsettled Balance:________________________________

TOTAL AMOUNT:___________________________________

Received By:

MEMBER/CLAIMANT DATE CONTACT NUMBER

Signature over Printed Name

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Requirements in Availing the Death Aid Benefits

1. Photocopy of Death Certificate

2. ID of the member/ claimant
3. Accomplish the Claimant form to be given by LCPSTEA

Who May Claim the Benefits

1. Member ( For their beneficiaries)

2. Any of the declared beneficiaries of the members upon presentation of proper
documents .

Requirements in Availing the Loyalty Benefits

1. Endorsement from the School Head stating that he/she is a retired member from their
school.
2. Original and photocopy of the ID of the member/ claimant
3. Accomplish the Claimant form to be given by LCPSTEA
4. Clearance from the School and District Treasurer.

Who May Claim the Benefits

1. Member
2. Any of the declared beneficiaries of the members upon presentation of proper
documents .

Health Aid Benefits

The following sickness will be given priority in LCPSTEA Health Aid Benefits/Assistance
and this will be for members only.

 CANCER
 MAJOR OPERATION excluding Caesarian Operation.
 DIALYSIS
 CHEMO THERAPY
 TRANSPLANT
 STROKE
Assistance could be availed by a member only once a year.