Rangtay sa Pagrang-ay Microfinance, Inc.

Microinsurance Program (MIP)

Notice of Insurance Claim
Branch:_______________________________________
Name of Principal member:______________________________________________________
Name of Deceased:_____________________________________________________________
Client Dependent
Date Enrolled: _______________________ Date of Death:_______________________

_____________________________ ________________________________
Signature over Printed Name of PA Signature over printed name of BM
MICRO-INSURANCE REQUIREMENTS: (Check list) TO BE FILED WITHIN 75 DAYS FROM DATE OF DEATH
¨  back to back photocopy of Insurance and CAP FORM
¨  back to back photocopy of Application form
¨  Certificate of Death with registry number (if xeroxed, must be certified true copy)
¨  Physician Statement
¨  Claimant Statement
¨  Medical Records/Certificate
¨  If the deceased died due to accident, please provide 1 original copy of POLICE REPORT.
¨  Birth certificate of insured and beneficiary
¨  Marriage certificate if the insured is married
¨  Valid I.D (in its absence, Barangay certification or affidavit of disinterested person
¨  For Common Law, provide certification from Barangay Official (at least 1 year of living together)
¨  Loan ledgers for the last 3 cycles
Remarks (For MIP use only):

Rangtay sa Pagrang-ay Microfinance, Inc.

Microinsurance Program (MIP)
Notice of Insurance Claim
Branch:_______________________________________
Name of Principal member:______________________________________________________
Name of Deceased:_____________________________________________________________
Client Dependent
Date Enrolled: _______________________ Date of Death:_______________________
_____________________________ ________________________________
Signature over Printed Name of PA Signature over printed name of BM
MICRO-INSURANCE REQUIREMENTS: (Check list) TO BE FILED WITHIN 75 DAYS FROM DATE OF DEATH
¨  back to back photocopy of Insurance and CAP FORM
¨  back to back photocopy of Application form
¨  Certificate of Death with registry number (if xeroxed, must be certified true copy)
¨  Physician Statement
¨  Claimant Statement
¨  Medical Records/Certificate
¨  If the deceased died due to accident, please provide 1 original copy of POLICE REPORT.
¨  Birth certificate of insured and beneficiary
¨  Marriage certificate if the insured is married
¨  Valid I.D (in its absence, Barangay certification or affidavit of disinterested person
¨  For Common Law, provide certification from Barangay Official (at least 1 year of living together)
¨  Loan ledgers for the last 3 cycles
Remarks (For MIP use only):
 Date:___________________
Cycle: __________
_____
_____________

___________________
r printed name of BM
Branch Use

Date:___________________
Cycle: __________
_____

_____________
___________________
r printed name of BM
Branch Use