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FG Claim Application

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JP Labininay
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19 views1 page

FG Claim Application

Uploaded by

JP Labininay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Fidelity Guarantee

Claim Application form


CN.: -____________

Date Filed : ______________________________ Policy : _____________________


Assured/ Coop : ______________________________ Address : _____________________
Employee Name : ______________________________ Inception Date: _____________________
Date of Accident : ______________________________ Official Receipt No. _____________________
Place of Accident : ______________________________ Date : _____________________
Contact Number : ______________________________ Noticed of Loss : _____________________
Nature of Loss: ____________

Type of Claim : FALSIFICATION : SHORTAGE : DISHONESTY:

I hereby adhere to submit all nesiciated documents listed on perforated acknowledgement receipt part of this application of claim.
This is not an admission of liability but only for the purpose of expediting settlement if ever upon our examination, verification and evaluation it
appears that the company is liable.
CLIMBS its assigned adjuster & agents reserve the right to require additional documents/record relevant on the investigation examination of a
claim whenever necessary.
Your claim will not be processed unless the pertaining documents are complied and fully submitted.
Please note that claims are only valid within 6 months from the date of loss occurred.

Claimant : _______________________________________ Date : _______________________________


Applicant

Remarks: Complete : Incomplete:


Encl:
_______________________________________________________________________________________

-------------------------------------------------------------------------------------------------------------------------------------------------
Please submit all checked required documents. CN.: ____________

Acknowledgement
FG Claim Requirements
 Notice of Loss
 Coop Endorsement Letter
 Copy of Policy
 CLIMBS OR Photocopy
 Police Special Written Report
 Incident Report
 Complaint Affidavit
 Cash count sheet
 Audit & Inventory Committee Report
 Clear Photographs
 Check Deposit Slip

Other additional requirements as needed:


*Warrant of Arrest
*Court Verdict
*Employee History / Employment Contract /Termination of Employment Letter / Letter of Resignation (Action taken by the Coop to the
_________________________________________
employee regarding the situation)
Any additional documents as necessary

Received By: _________________________________________


Date : _________________________________________

CLIMBS Life and General Insurance Cooperative- Head Office CLIMBS Bldg., Zone 5 Bulua National Hi-way Cagayan de Oro
City 9000 Phils. Telefax Number (088) 852- 4281

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