Republic of the Philippines

Province of Tarlac
Municipality of Camiling
BARANGAY BILAD

Office of the Punong Barangay

ENDORSEMENT OF CLAIM

December 1, 2015

TO: ARLENE M. VILLANUEVA

Branch Manager
GSIS Tarlac Branch Office
San Roque, Tarlac City

Dear Madam:

I, Albert B. Jose, Punong Barangay of Barangay Bilad, Camiling, Tarlac, that we had taken a group
insurance policy from your company against policy number ____________ on _________ (date) for the
Barangay Officials and Personnel.

With deep regret this is to formally endorse our claim that one of the barangay officials in the person of
former Barangay Kagawad Victor Sagun Lactaoen passed away on the night of November 24, 2015 on or
about 6:26 in the evening due to a motorcycle accident. Attached herewith are copies of the medical
certificate and police report as well as the death certificate for your reference.

Even though nothing can repair our loss but since his wife was dependent on him and she was the
nominee of the policy, I would like to file this claim with you.

Your forthright resolution to this pressing need will be of eternal gratitude. We are hopeful that you will
take proper steps to redress our grievance at an early date. We beg to remain.

We look forward to a quick resolution to our claim.

Thanking you in anticipation.

Best regards,

ALBERT B. JOSE
Punong Barangay
Bilad, Camiling, Tarlac
 FORMAL NOTICE OF CLAIM

TO: ARLENE M. VILLANUEVA

Branch Manager
GSIS Tarlac Branch Office
San Roque, Tarlac City

Re: Personal Accident

Claimant: Lyzie G. Lactaoen
Insured: Victor S. Lactaoen
Policy #: GSIS
Date of Loss: November 24, 2015

Dear Ma’am:

Please be advised that I am pursuing a claim of life insurance for personal loss as a result of a self-incurred
accident which occurred on November 24, 2015 at at Barangay Bilad, Camiling, Tarlac.

Currently, my husband former Barangay Kagawad Victor S. Lactaoen, an insured member of GSIS under the
Group Insurance with Policy Number of Barangay Bilad, Camiling, Tarlac, that he was buried and I ‘am
pursuing in good faith, in hopes of settling the claim amicably.

Attached herewith are copies of the medical certificate and police report as well as the death certificate
for your reference.

Thank you for your anticipated cooperation in this matter.

Sincerely,

Lyzie G. Lactaoen