Death Claim Form

To be completed by Attending Physician

Policy Number
Please fill in block letters and tick the appropriate boxes and circles.
1. Information on the Deceased Insured

Title First Name Middle Name Last Name Ext Name

Age at time of Death Last Residence Address of the Deceased

2. Association with the Deceased Insured

a. Are you related to the deceased? Yes No
b. Did you personally know the deceased? Yes No
c. How long have you known the deceased?
d. Were you the attending physician during the deceased's last illness or accident? Yes No
e. Were you present when the death occured? Yes No
f. Did you personally see the remains of the deceased? Yes No
3. Circumstances on the Death of the Deceased Insured (Please provide COMPLETE and detailed answers to the following questions)
1. Provide details of death

Date of Death (mm/dd/yyyy) __ __ / __ __ / __ __ __ __ Place of Death

Immediate Cause of Death

2. If death is due to medical condition or natural cause, please provide details: (Please use extra sheet of paper if needed)

Give complete history of medical

condition/illness including the dates
it was experienced

Sign/s or Symptom/s Experienced

Date symptoms first discovered
How long did the deceased suffered
from the condition

3. If death is due to violent incident, please provide details: (Please use extra sheet of paper if needed)
State the nature of the
violent incident
Date (mm/dd/yyyy) Time of Accident Place of Accident
Details of the accident
__ __ / __ __ / __ __ __ __ __ __ : __ __ AM PM

Narrate completely how the accident

happened

3.1. Was the patient under the influence of alcohol, improper use of drugs or narcotics at time of accident? Yes No
If Yes, what cause you to believe so? Please give details.

4. What were the first indications of the deceased's failing health?

Date it was first noticed by the deceased

5. Please provide date when you were first consulted for the condition which either directly or indirectly caused the death?

Date of your first attendance with the deceased

What was the chief complaint of the deceased

What was your diagnosis then and treatments

given to the deceased

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 POLICY NUMBER: __________________________

6. Who referred the deceased to you? Please indicate his/her full name and address.

7. Have you previoulsy attended the deceased during his/her last illness? Yes No
Please give particulars of any illness or investigations for which the deceased has consulted with you:
Complaints and Findings Diagnosis Date Attended Treatment or Medical Management

8. Did the deceased suffer from any other illness, disease or injury before death that were not mentioned above?
If Yes, please provide details. Yes No
Nature of illness, disease or injury Inclusive dates of illness If confined or treated, Name of Clinic/Hospital

9. Please answer the following questions.

Question YES NO Please provide details to the "YES" answer
a. Did the deceased have any family history of medical
illnesses which may have led to or contributed to the
cause of the death?

b. Was the death due to suicide / homicide / accident?

c. Did the deceased smoke cigarettes/cigars or consume

any other tobacco products or prohibited drugs?

d. FOR FEMALE ONLY: Was the death related with or a

complication of pregnancy?

10. Was the deceased ever confined in a hospital or other institution for any condition or injury? Yes No
Please provide details.
Name of Hospital / Clinics / Other Institution Inclusive Dates Reason of confinement

11. Name other physicians who attended to the deceased for any illness / disease or injury.
Please provide details.
Name and address of Physician/s Inclusive Dates Diagnosis / Treatment given

12. Was there an autopsy or other post mortem examination made on the body of the deceased? Yes No
If yes, please give a copy of the report and provide details below:
Date of Autopsy Place of Autopsy

Result

13. Do you consent FWD to relase the information you provided in this report to the deceased's family and/or
claimants when requested to explain our decision? Yes No

4. Affirmation Section

m m d d y y y y
Place of signing Date: / /

Attending Physician's Signature Complete Clinic/Hospital Address Telephone number / Mobile Number
over Printed Name

Lic No:
PTR No: Field of Specilalization Email Address

5. Data Protection
FWD has appointed a Data Protection Officer to handle any inquiries relating to your personal information. If you would like to obtain a copy of the
FWD Life Insurance Corporation Personal Data Policy and Practices, please write to the Corporate Data Protection Officer at 19/F, W Fifth Avenue
Bldg., 5th Avenue cor. 32nd Street, Bonifacio Global City, Taguig City 1634, Philippines.
PLEASE DO NOT SIGN ON A BLANK FORM.

CLAIMFORM DC-aps Nov2016 v2 Page 2 of 2

Death Claim Form
To be completed by Each Claimant

Policy Number FWP/FSC Code

Please fill in block letters and the tick appropriate boxes and circles. Requests received by FWD service counters within the cut-off time of 2:00 PM
will be processed within the day. Requests received beyond cut-off will be processed the next business day.
1. Information on the Deceased Insured Member
Name of Deceased Insured
Title First Name Middle Name Last Name Ext Name

Date of Birth (mm/dd/yyyy) Place of Birth Country of Birth Nationality

Occupation at the time of Death Name of Employer at the time of Death

Complete Residence Address at the time of Death

No. and Street Barangay/Subdivision

Municipality,Town/City Province/Country Zip Code

2. Circumstances of the Death of the Deceased Insured Member

Details of Death
1. Provide details of death
a. Date of Death __ __ / __ __ / __ __ __ __ d. Place of Death
b. Date of Interment __ __ / __ __ / __ __ __ __ e. Place of Interment

c. Cause of Death

2. Describe circumstance of death. Please fill in the table.

2.1. For Death due to Medical Condition or Natural Causes/Illness:

a. Give complete history of medical condition/illness

b. Sign/s or Symptom/s experienced and indications of

deceased's failing health
c. When did the symptoms and indications of deceased's
failing health first discovered
d. How long did the deceased suffered from the condition
2.2. For Death due to Accident/Violent incident
a. State the nature of the incident:
b1. Date of Accident: __ __ / __ __ / __ __ __ __ b2. Time of Accident ___ ___ : ___ ___ AM PM
c. Place of Accident (give exact address/location)

d. Narrate completely how the accident happened:

e. Where was insured before the accident happened?

f. What was insured doing before the accident happened?

g. If an employee, was he doing his duties as such when the

accident happened? If "yes", please give details.
h. In case of vehicular accident, was Insured then a
passenger in a vehicle? If "yes" please give details of Type of Vehicle:
the vehicle and attached photocopy of Insured's Plate Number:
driver's license (plasticized) and renewal receipt of Registration Year:
payment
i. Who was with the deceased when the accident happened?
Name Address
j. Names and addresses of witnesses to the accident

2.3. Give the name and adress of the Physician who first attended the deceased for his medical condition/accident:
Name of Physician Address of Physician/Hospital Inclusive Dates Diagnosis/Treatment
(From - To)

3. When did the deceased last attended his usual work?

4. Other illness/ess, condition or injuries the deceased suffered from before death:
Other illness/es the deceased suffered from before death Inclusive Dates of Illness

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 POLICY NUMBER: __________________________

5. Name and Address of Physicians consulted by the deceased within the last 5 years.
Name of Physician Address of Physician/Hospital Inclusive Date Diagnosis/Treatment

6. Did the deceased have any other insurance coverage? Yes No

Name of Insurance Company Policy Number Amount of Insurance Address of insurance

3. Beneficiary's Information and Affirmation

Title First Name Middle Name Last Name Ext Name

Date of Birth (mm/dd/yyyy) Place of Birth Country of Birth Nationality

Gender Present Age Relationship with the Deceased Insured

Male Female
TIN/SSS/GSIS No. Contract Information: (Country Code)(Area Code)(Telephone/Mobile Number) Email Address:

Complete Address
No. and Street Barangay/Subdivision

Municipality,Town/City Province/Country Zip Code

4. Claimant's Information and Affirmation (If Claimant is different from the named Beneficiary, please accomplish details below)
If you are filing in behalf of a minor beneficiary:
1. In what capacity are you filing this claim for? as Trustee as Guardian
2. As guardian of the minor beneficiary, have you not been disqualified by court or law from
Yes No
exercising the right to administer the property of such minor?
3. Is the minor beneficiary under your actual custody and support? Yes No
Claimant's Information
Title First Name Middle Name Last Name Ext Name
Relationship with the Beneficiary Contact Number Email Address:

Complete Address
No. and Street Barangay/Subdivision

Municipality,Town/City Province/Country Zip Code

5. Data Protection
FWD has appointed a Data Protection Officer to handle any inquiries relating to your personal information. If you would like to obtain a copy of
the FWD Life Insurance Corporation Personal Data Policy and Practices, please write to the Corporate Data Protection Officer at 19/F, W Fifth
Avenue Bldg., 5th Avenue cor. 32nd Street, Bonifacio Global City, Taguig City 1634, Philippines.
6. Declaration
I UNDERSTAND AND CONFIRM THAT:
1. The information I have provided above and in any supporting documents and/or records (collectively defined as this 'Form') are true and
complete and shall form part and be the basis of the assessment of this request and approval. I understand that providing false, inaccurate
or incomplete information may result in my transaction request being denied and shall give FWD the right to repudiate the claim or forfeit
all payments to be made.
2. I authorize FWD and/or its duly authorized representative to secure whatever information and/or records from any employer, any physician,
hospital/clinic, other medically related facility, and any organization/institution or person, who has any records and/or knowledge with
regards to the Insured/Deceased's Illness, sickness, condition, disability and/or injury as described in this Form.
3. The payment by FWD of the proceeds of this claim shall release and forever discharge FWD from all actions, claims and demands on all
matters involving the said benefit or amount.
4. Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and / or imprisonment of two (2)
years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for the payment of
a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to present or use the
same, or to allow it to be presented in support of any claim.

m m d d y y y y
Place of signing Date: / /

Beneficiary/Claimant's Signature over Printed Name FWP/FSC/Witness

Note: (1) If this form will be signed outside the Philippines, please have the form authenticated by the nearest Philippine Embassy or Consulate
in your locality. (2) The witness should be a disinterested adult person.
PLEASE DO NOT SIGN ON A BLANK FORM.

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 Employer / Policy Owner's Statement
To be completed by the Employer/Policy Owner or its duly Authorized Representative

Policy Number
Please fill in block letters & tick the appropriate boxes and circles.
1. Employee / Member's Information
Title First Name Middle Name Last Name Ext Name

Date of Birth (mm/dd/yyyy) Place of Birth Country of Birth Nationality

Job/Position Civil Status

2. Employer/Policy Owner's Information

Name of Employer/Policy Owner:

Nature of Business: Business TIN:

Address of Employer/Policy Owner:

No. and Street Barangay/Subdivision

Municipality,Town/City Province/Country Zip Code

Email Address: Contact Number:

3. Employment Details

1. Date of Regular Employment (mm/dd/yyyy)

2. Date of first premium remittance for member (mm/dd/yyyy)
3. Last premium remittance for member covers the period (mm/dd/yyyy)
4. Date last reported to work (mm/dd/yyyy)
5. Reason he ceased working

4. Claim Details

For Living Claim For Death Claim

Date of disability/illness/accident/confinement (mm/dd/yyyy) Date of death (mm/dd/yyyy)

Diagnosis Place of Death

Is member reporting to work now? Yes No Cause of Death

If Yes, when did he return to work?

If No, when he is expected to return to work? ______________

5. Coverage Details

Amount of Claim:

Insurance benefit is payable to:

6. Declaration
I UNDERSTAND AND CONFIRM THAT:
1. The information I have provided above and in any supporting documents and/or records (collectively defined as this 'Form') are true and
complete and shall form part and be the basis of the assessment of this claim request and approval.
2. Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and / or imprisonment of two (2)
years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for the payment of a
loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to present or use the same,
or to allow it to be presented in support of any claim.
m m d d y y y y
Place of signing Date: / /

Certified by Authorized Signatory:

Name of Employer/Policy Owner Signature over Printed Name / Position

PLEASE DO NOT SIGN ON A BLANK FORM.

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