APPLICATION FOR MRI/SRI CLAIM

_________________________
(Branch)

(TYPE OR PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS)

REASON FOR CLAIM (Check appropriate box)

 DEATH  PERMANENT TOTAL DISABILITY  TERMINAL ILLNESS

Date of Death: _____________________ Date of Injury/Sickness Sustained: ________________________
(MM/DD/YYYY) (MM/DD/YYYY)

BORROWER/CO-BORROWER DETAILS
MARITAL STATUS
LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME MAIDEN NAME
(for married women) Single/Unmarried
Married
Widow/er
DATE OF BIRTH (MM/DD/YYYY) AGE PRINCIPAL BORROWER HOUSING ACCOUNT NO. Legally Separated
CO-BORROWER Annulled
NAME OF OTHER BORROWER/S, IF APPLICABLE
HOUSING NAME EXTENSION PRINCIPAL/
LAST NAME FIRST NAME MIDDLE NAME
ACCOUNT NO. (e.g., Jr., II) CO-BORROWER

CLAIMANT/BENEFICIARY/HEIR ADDRESS AND CONTACT DETAILS

LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME RELATIONSHIP TO THE DECEASED
BORROWER/CO-BORROWER

PRESENT ADDRESS CONTACT DETAILS

Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name Subdivision Home

Cell Phone (Required)

Barangay Municipality/City Province/State/Country (if abroad) ZIP Code
Email Address (Required)

CERTIFICATION

I certify that I have read and understood the contents hereof, including the guidelines and instructions indicated at the back portion
of this form.

I certify that the foregoing information/statement is to my knowledge, true, correct, complete and updated. I further certify under
pain of perjury that the signature appearing above my printed name below is genuine and the documents submitted with this form are true
reproduction of the original documents.

I authorize Pag-IBIG Fund to share my personal information and other details of my application with other government agencies
and third parties, as may be necessary, subject to the limits under Republic Act No. 10173 (Data Privacy Act of 2012), and its implementing
Rules and Regulations.

I hereby declare that the names of surviving heir/s listed in the submitted Proof of Surviving Legal Heirs are the only parties legally
entitled to the benefits under the MRI Policy.

I undertake to indemnify Pag-IBIG Fund upon demand for any liabilities that may incur in the event of the existence of other
beneficiary/ies or heir/s, any fraud, mistake, falsity, or misinterpretation in connection with my claim under the MRI policy.

I understand that the approval of this application is subject to pertinent provisions of the implementing rules and regulation of the
Pag-IBIG Fund. I agree that all information obtained by Pag-IBIG Fund shall remain its property whether the application has been granted
or not.

_________________________________________ ___________________________
Signature of Borrower/Claimant/Beneficiary/ Date
Heir Over Printed Name

THIS FORM MAY BE REPRODUCED. NOT FOR SALE

 GUIDELINES AND INSTRUCTIONS

A. WHO MAY FILE

A Pag-IBIG Fund housing loan borrower, his heir/s or beneficiary/ies may file the insurance claims
with complete requirements upon the occurrence of any of the following grounds on or after November
1, 2014.

1. Permanent Total Disability

1.1. The housing loan borrower or his beneficiary/ies may file for MRI/SRI claim due to PTD;
provided, the following conditions are present:
a. Totally disabled by bodily injury or disease;
b. Prevented from engaging in any occupation for compensation or profit, from performing
the normal activities of life; and
c. Disabled for a continuous period of at least six (6) months;
1.2. Borrowers who are at least eighteen (18) years old but have not attained their 65th birthday
shall be allowed to file MRI/SRI claim due to PTD.

2. Terminal Illness Living Benefit

2.1. A Pag-IBIG housing loan borrower, who has been diagnosed with Terminal Illness, or his
beneficiary/ies may file MRI/SRI claim with complete requirements; provided said illness is
expected to result in the insured's death within twelve (12) months from the date of the
diagnosis of such illness by an acceptable licensed physician. Said date when such illness
or injury was diagnosed must be on or after November 1, 2014
2.2. Borrowers who are at least eighteen (18) years old but have not attained their 70th birthday
shall be allowed to file MRI/SRI claim due to Terminal Illness.
2.3. In case of claim that can be both filed against Permanent Total Disability and Terminal Illness,
only one benefit can be utilized by the insured.

3. Death
3.1. The heirs/beneficiaries of deceased borrowers shall be allowed to file MRI/SRI claim,
provided the deceased borrower is at least eighteen (18) years old and has not attained his
70th birthday at the time of death.

B. HOW TO FILE

The housing loan borrower or heir/s or beneficiary/ies shall accomplish and print this application form
back-to-back. Then, submit with the documentary requirements indicated in the Checklist of
Requirements for Application of Mortgage/Sales Redemption Insurance Claims (HQP-HLF-715) to any
Pag-IBIG Branch or through e-mail. Processing of application shall commence only upon submission
and presentation of original copies of complete documents.

C. APPLICATION OF INSURANCE PROCEEDS

1. In case of PTD/Death of the borrower, Pag-IBIG Fund shall apply the MRI/SRI proceeds to the
entire outstanding obligation as of date of PTD/Death of the said borrower. The excess MRI/SRI
proceeds after application to the outstanding obligation as of date of PTD/Death, if any, shall be
released to the borrower or his beneficiary/ies.

In case of tacked loans and the MRI/SRI proceeds is not enough to fully settle the entire
outstanding obligation, the remaining borrower/s or heir/s or beneficiary/ies must still settle the
outstanding obligation through any of the following modes:
a. Full payment
b. Re-documenting the housing loan application
c. Dacion En Pago
d. Revised Amortization Scheme

2. The MRI/SRI proceeds due to Terminal Illness shall be considered as regular amortization
payments.