APPLICA (PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS) LINZ) OQ beat Date of Death: = (WaMDDIVY¥Y) Corte: LASTNAME —FIRSTNAME NAME EXTENSIC Loon ON FOR MRI/SRI CLAIM (Granch) Ceca ee PERMANENT TOTAL DISABILITY. CITERMINAL ILLNESS '© of inury / Sioknoss Sustained: __ v (MMIDDIYYYY) ee oer (@9., Jr.) MIDDLE NAME MAIDEN NAME | MARITAL STATUS (formaried women)| ClSinglerUnmaried OMarriea (umopivyvy) Oraie Oco.2¢ Owidowier Ohesally Separates Dannutted \L BoRROWER | HOUSING ACCOUNT NO XOWER N(@o. Jr.) MIDDLE NAME | RELATIONSHIP TO THE BORROWERICO-BORROWER UUniuRioom No., Floor Building Name Lot No., Block No., Phase Barangay CONTACT DETAILS Home oe House No. Street Name Subdivision Municipaliyicity Pr | hereby certify, under pain of Perjury that my sig documents are true reproductio N of the original doe e’StateCountry (abroad) ZIP Code __| Cell Phone. Email Address Signature of Borrower/Claimant/Benefici Heir Over Printed Name THIS FORM Me Date ‘REPRODUCED. NOT FOR SALEGUIDELINES AND INSTRUCTIONS A. WHO MAY FILE A20-181G Fund housing loan borrower, his hei/s or beneficiaries may fie the insurance claims with complete Feauirements upon the occurrence of any of the following grounds on or afier November 1.2014. 1. Permanent Total Disability 1-1. The housing loan borrower or his beneficiaryies may fle for MRUSRI claim due to PTD; provided, the following conditions are present: @. Totally disabled by bodily injury or disease; ® Prevented from engaging in any occupation for compensation or profit from performing the normal activities of life; and ¢. Disabled for a continuous period of at least six (6) months; 12) Brrrowers vio are atleast eighteen (18) years old but have not attained their 65th birthday shall be allowed to file MRUSRI claim due to PTD. 2. Terminal iliness Living Benefit 21. A Peg-IBIG housing loan borrower, who has baen diagnosed with Terminal lines, of his beneficiaries may file MRVSRI claim with complete requirements; provided said Cesultin the insured's death within tweive (12) morths from the date of the diagn by an acceptable licensed physician, Said date when such illness or injury was dha of after November 1, 2014 Borrowers who are at least eighteen (18) years old allowed to file MRUSRI claim due to Terminal lines 2.3. In case of claim that can be both fled against Permanent Total Disability one benefit can be utilized by the insured 3. Death 3-1. The heirs/beneficiaries of deceased borrowers shall be allowed to file MRUSRI claim, provided the Geceased borrower is at least eighteen (18) years old and has not attained his 70th birthday at the time of death, illness is expected \sis of such iliness |gnosed must be on 22. ‘ut have not attained their 70th birthday shall be and Terminal liness, only B. HOWTO FILE The housing loan borrower or heir/s or beneficiarylies shall si documentary requirements indicated in the Checklist of R: Redemption insurance Claims (HOP-HLF-715) to any Pag pplication shall commence only upon submission of complete ‘ubmits duly accomplished application form and ‘equirements for Application of Mortgage/Sales 'BIG Branch or through e-mail. Processing of documents. C. APPLICATION OF INSURANCE PROCEEDS 1, In case of PTDIDeath of the borrower, Pag-| outstanding obligation as of date of PTDIDeat pplication to the outstanding obligation as of oF his beneficiarylies, 'BIG Fund shall apply the MRUSRI proceeds to the entire th of the said borrower. The excess MRVSRI proceeds after date of PTD/Deatth, if any, shall be released to the borrower In case of tacked loans and the MRUSRI proceeds is not enough to fully settle the entire outstanding obligation, the remaining borrower/s or heir! JS or beneficiarylies must still settle the outstanding obligation through any of the following modes: a. Full payment b.Re-documenting the housing loan application ©. Dacion En Pago d. Revised Amortization Scheme. 2. ‘The MRI/SRI proceeds due to Terminal lliness shall be considered as regular amortization payments.© APPLICATION FOR MRI/SRI CLAIM (Branch) (PRINT ALL ENTRIES IN BLOCK OR CAPITAL LETTERS) cheek purpo (oeatn Ci rermanentroratoisaaiuity [7] TERMINAL ILLNESS: NAME OF BORROWER (Last Name, Fret Name, Name Extension, Middle Name) HOUSING! INT NO. | DATE OF BIRTH |AGE | SEX | CIVIL STATUS. Cernciea: sorrower [Jco-sonroner | POUSNS ACCOUNT NO, |B [DATE OF DEATH [CAUSE OF DEATH DATE OF TERMINAL NAME OF TLLNESSIPTO ILLNESSPTD NAME OF BENEFICIARY (Last Name, Fist Name, Name Exiension, Middle Name) | RELATIONSHIP TO THE BORROWER /ADORESS OF BENEFICIARY (No,, Steal, Subdivision, Barangay, Gly, Muniapal ounce) CONTACT NUMBERS (Home/obile Numiber/Office ax Number) | EMAIL ADDRESS Boneficiary’s Signature Scene eens 7 a " . - ‘DEVELOPERIORIGINATING BANK ~ TAREOUTINOR DATE - TOAN TERM VERFIED BY DATE ‘aR PRERATUN REMARKS S jReauRewents: = 'A. Permanent Tota DisabltyTerminal ness 4), Tota ang Permanent Dsabity For Teminal iness Fem 2. Insured’ Statement of Disabiy NOTE: Prefoma of am No 1 and2 ate avaabe at any Pag BIG Fund fee 3. Complete Mesa Records 5 PSA Bith Contest ot apts rowers marie, Borrower's PSA Marriage Contact a 4 erginal and 1 photocony each) }—1—orowers PSA Deatn Certcate 2 Borower’s PSA Binh Cerfese or Baptismal 3. fborower ssn, PSA Cerificate of Ne Mariage (CENOMAR) and PSA Mariage Contact of Parents 4 lfborowers marres, PSA Mariage Contact and Aavsoy of Meta & Potce Report i cea ae to accent ue) Naarzed Pon of Surivg Legal Hara ltted Atiavt of Guaranati twin easentren below 18 years, chee are pysicalimenaly incompetent) Pah Bit Certcate of at Craaren o Baptismal (win chidtacen) or Suviing Parents 0 Stange (oars hy PSA Mariage Contract fal Femaie Legal Age Ctivn (wih chischiaren).f oppcane, NOTE: For mare female chil of te cee 10. PSA Death Certete of 11. Specal Power of atorney. appleabie, 12, Two 2) Val 1D of beneianyes, Notes: Locaittuniipal Ci Registrar Certfied True Coy (ith sta rainy signe by any of ts authozed oer + Submit Notarzed Joint atau of 2 Disteresieg Persons on ay o he flowing 1: Tees dsrepancy onthe borrower foeneanye’ data 3 Tere i no record ttm the PSAVLoEa| Cul Rogar Ped tat twas afeady endorsed to PSA) may be evmied ony if cerifed an ‘Additonal Requirements For Contetable Cis (Died wihin the period oft yar fom tkeout dala date) 1 Complete Medical Records 2. Corcate of Atending Physician 5. Carateate ot Employment ox Daly Tine Recor showing the last date the inured was al o repr for work NOTE: The submited documents wil be reviewed and evaluated, subject tots, tems and conditions of your coverage.ACKNOWLEDGEMENT RECEIPT (Application for MRUSRI Claim) NAME OF BORROWER (Last Name, First Name, Name Exension, Middle Name) HOUSING ACCOUNT NO, RECEIVED BY: REMARKS (Gignature of Pag-BIG Fund's Authorized Signatory 0 pate me: | GUIDELINES AND INSTRUCTIONS ‘A. WHO MAY FILE: ‘A PagitBIG Fund housing loan borrower, his heirs or beneficia rylies may fila the insurance claims with complete equitements upon the eccurrence of any ofthe following grounds, ‘on or after November 1, 2014 4. Permanent Total Disability 114, The housing loan Borrower or his following conditions are present: The borrower becomes totaly disabled fora continuous period of at least six (6) months; 'b. He was prevented from engaging in any occupation for compensation or profit an & He has been deciared by the attending physician to be so disabled for Ife due to bodily injury or cisease on or after November 1, 2014. 12. Borrowers who are atleast eightaen (18) years old but have not attained their 65th binhday shall be allowed to fle MRUSRI ciaim due to PTD. is beneficianyies may file for MRUSRI claim due to PTD: provided, the 2. Terminal iiness Living Benefit 2.4, A PagsIBIG housing loan borower, who has been dlagnosed with Terminal ness, o his benliianyies may file MRUSR! claim with complete requirements; provided said illness is expected to result i tre insured's death within welv (12) months from the date of the diagnosis of such ilness by an accaplable licensed physician. Said date when suchilness or injury was diagnosed must be on of alter Noone 4, 2014 2.2, Borrowers who ara atleast eighteen (18) years old but have not alained their 7Oth birthday shall be alowed to file MRUSRI claim due to Terminal liness 23, __In-case of claim that canbe both fied against Permanent Total Disablly nd Terminal ness, only one benefit can be utiized by the insured 3. Death 3:3 Upon the death ofthe housing loan borrower, his heitls or beneficiaryies may file the MRUSRI claims. 32 Death dve to suicide shall not be a cause fo exclude borrowers from fling the MRUSRI eising 53. The heirs/beneficiaries of deceased borrowers shall be allowed to fle MRUSRI claim. provided the leceased borrower isa least eighteen (18) years oki and has not attained his 70th bidsy at he tine of death 8. HOWTO FILE ‘The housing loan borrower or her's or beneficiaries shal: 4. Accomplish application form for MRISRI Claim 2. Submit complete application, together with the required dk application shall commence only upon submission of comgl ©. APPLICATION OF INSURANCE PROCEEDS t Seiaaar ae Death of the borrower, Pag-18IG Fund shal aply the MRUSRI proceeds tothe entre outstanding Soigation as of date of PTD/Death of the said borrower. The excess MRUSRI proceeds aller sopicaien ne cwstanding obligation 29 of dete of PTOYDeath, i any, shallbe released tothe borrower er Ns benshsaryiow thosonarincked loans end the MRISRI proceeds isnot enough to uly sete the ene outstanding obigation, tonsa nng botrowerls or hes or beneficaryies must stl sete the outstanding cbigaton trough ence s following modes: Full payment b. Re-documenting the housing loan application © Dacion En Pago Revised Amortization Scheme focuments to any Pag-IBIG Branch. Processing of ete documents ‘The MRUSR! proceeds due to Terminal ness shall be considered as regular amortization payments AUTHENMICATIONNSTANCES: THE ORIGINAL COPY OF THE DOCUMENTS MUST BE PRESENTED FOR AUTHENTICATION FOR ALL PHOTOCOPIED DOCUMENTS SUBMITTED,