HQP-HLF-080 HQP-HLF-080

APPLICATION FOR APPLICATION FOR

INSURANCE CLAIMS INSURANCE CLAIMS

Please check purpose Please check purpose

Earthquake Flood Other Allied Perils Earthquake Flood Other Allied Perils
Fire Typhoon ______________ Fire Typhoon ______________
Date Filed: ___________ File No. ___________ Date Filed: ___________ File No. ___________
BORROWERS DATA BORROWERS DATA
Last Name First Name Name Ext. Middle Name Last Name First Name Name Ext. Middle Name

Maiden Name (For married women) Sex HL Account No. Maiden Name (For married women) Sex HL Account No.
Male Male
Female Female
Change in Marital Status Date of Birth Change in Marital Status Date of Birth
Single/Unmarried Married Widow/er Single/Unmarried Married Widow/er
Legally Separated Annulled Legally Separated Annulled
Company/Employer/Business Name Company/Employer/Business Name

Company/Employer/Business Address Tel. No. Company/Employer/Business Address Tel. No.

Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province) Property Location (No., Street, Subdivision, Barangay, City, Municipality, Province)

Contact Nos. (Home/Mobile Number/Fax No.) Date of Occurrence Contact Nos. (Home/Mobile Number/Fax No.) Date of Occurrence

Borrowers Borrowers
Signature Signature

FOR BILLING AND COLLECTION DEPARTMENT/LCMRD FOR BILLING AND COLLECTION DEPARTMENT/LCMRD
Age Upon Age Upon
HL Account No. Co-Borrower(s) Loan Value HL Account No. Co-Borrower(s) Take-out
Loan Value
Take-out
1. 1.
2. 2.
3. 3.
4. 4.
Developer/Originating Bank Take-out Date Developer/Originating Bank Take-out Date

Program Program
FOLIO 1 CTS EHLP FOLIO 1 CTS EHLP
PI Express Lane (W1) UHLP/7B PI Express Lane (W1) UHLP/7B
OH Elite (W1) RL 9507 OH Elite (W1) RL 9507
Overhang Regular (W2) RL 8501 Overhang Regular (W2) RL 8501
Cir. 100 50M Others ______ Cir. 100 50M Others ______

Interest Rate Annual Premium Term Last Renewal Date Interest Rate Annual Premium Term Last Renewal Date

Verified by Date Certified by Date Verified by Date Certified by Date

Remarks Remarks Remarks Remarks

REQUIREMENTS: (3 copies each) REQUIREMENTS: (3 copies each)

1. Cost of damages/bill of materials; in case of total loss of property, it 1. Cost of damages/bill of materials; in case of total loss of property, it
must be duly signed by a licensed architect or civil engineer must be duly signed by a licensed architect or civil engineer
2. Photos of the damaged property 2. Photos of the damaged property
3. Formal Claim 3. Formal Claim
4. Non-Waiver Agreement 4. Non-Waiver Agreement
* Additional requirements may be required for submission by the * Additional requirements may be required for submission by the
Insurance Pool. Insurance Pool.

(April 2012) (April 2012)