Department of Interior and Local Government

PHILIPPINE COUNCILORS LEAGUE

CLAIM NO.
HOSPITALIZATION BENEFIT APPLICATION FORM DATE FILED
Name of Claimant

LGU/PROVINCE

Age Gender PCL I.D. #

Cellphone # Telefax # Email Address

Confinement Period Name of Hospital Sickness

Bank Name Bank Account # Bank Branch

I hereby certify that the above information and the This is to certify that the claimant herein is a
attached supporting documents are correct to the Member of Good Standing and endorsing it’s
best of my knowledge. approval.

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CLAIMANT’S SIGNATURE
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DATE
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SIGNATURE
MARIA ROSARIO EUFROSINA P. NISCE
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NAME OF THE PFP/CCP

To be filled by the PCL National Secretariat

CLAIM CATEGORIES
Check and verify before processing claim Medical Benefit Hospitalization Expenses
P 15,000.00 P 70,001,00 and above
O Medical Certificate/ Clinical Abstract P 12,000.00 P 50,001.00 – P70,000
O Photocopy of Hospital Bill P 10,000.00 P 40,001.00 – P50,000
P 8,000.00 P 30,001.00 _ P40,000
O Photocopy of Official Receipts
P 6,000.00 P 20,001.00 – P 30,000
( i.e. Room and Board, laboratory
P 4,000.00 P 10,001.00 – P 20,000
Professional Fees, Medicines, etc.)
P 2,000.00 P 4,000 – P 10,000
O Funds available for release P 1,000.00 below 4,000.00
NOTE:
Note: Please submit Original Copy or Certified In a term, a member in good standing can avail a
True Copy maximum Medical Benefit of P15,000.00 .
Certified by: Check Prepared by: Noted by:

JANETH E. DE CASTRO ANTONIETE L. NAVAL HON. BEETHOVEN M. BERMEJO

Claims-in-charge Accounting Assistant National Secretary-General
Date: Date: Councilor, Catbalogan City, Samar

Date Released Voucher Number Bank Deposit slip or

Acknowledgment Receipt