Philippine Prudential Life Insurance Co. - Personal Accident Insurance Claim Form
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3Philippine Prudential Life Insurance Co. Inc.
Personal Accident Insurance Claim
CLAIMANT’S STATEMENT
Instructions: Every question must be fully answered. The company reserves the right to require additional
information if deemed necessary.
Full Name of Claimant: _________________________________________________________________
Residence: __________________________________________________________________________
Relationship to the insured: _____________________________________________________________
Full name of Insured: ___________________________ Date of Birth: ___________________________
Employer: ___________________________________________________________________________
Date of Accident: _________________________ Place of Accident: _____________________________
Nature of injuries sustained: _____________________________________________________________
Period in which you were not able to perform: _______________________________________________
State what happened (You can use the back portion for additional information)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Name of attending Physician: ___________________________________________________________
Name of hospital / clinic: _______________________________________________________________
Complete address of hospital / clinic: _____________________________________________________
___________________________________________________________________________________
Are you entitled to receive compensation from government sources? Yes □ No □
If yes, check with agency & how much? O SSS __________ O GSIS _______________
O Medicare ______ O ECC ________________
Are you entitled to receive compensation from other private insurance companies or health maintenance
organization (HMO)? Yes □ No □
If yes, state the name of the insurance company/ies or HMOs and the amount you are entitled to.
COMPANY/IES
AMOUNT
_________________________________
________________________________
_________________________________
_______________________________
_________________________________
________________________________
I hereby certify that all the statement above are true and correct to the best of my knowledge and that I have not
concealed and material fact from Philippine Prudential Life Insurance Co. Inc. Thereby further authorize any
hospital, physician, or other person who has attended or examined me, to furnish Philippine Prudential Life
Insurance Co. Inc. or its authorized representative, and all information with respect to an illness or injury, medical
history consultation, prescriptions or treatment and copies of all hospital or medical records. A photocopy of this
authorization is considered effective and valid as the original.
_______________________________________________________
PRINT NAME OF CLAIMANT & SIGN OVER PRINTED NAME
Documents submitted together with this claimant’s statement:
Attending Physician statement
ORIGINAL official receipts
Statement of account from hospital / clinic
Itemized list of laboratory examination performed, supplies and medicines used with their
corresponding cost
Original doctor’s prescription, if medicine was bought outside the hospital
Police report / incident report, as applicable
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