CLAIMS QUESTIONNAIRE

ASSURED’S NAME: _____________________________________________________________

DRIVER’S NAME: _______________________________________________________________

MOBILE NO. / LANDLINE NO.: ____________________________________________________

EMAIL ADDRESS: _______________________________________________________________

1. Travel Information:
a. Purpose of Travel? _____________________________________________________
b. Origin of Travel? _______________________________________________________
c. Destination of Travel? __________________________________________________
2. Usage of Vehicle? _________________________________________________________
3. Relationship of the driver with the assured? ____________________________________
a. If hired, how was the driver compensated? _________________________________
b. Establish Driver's Authority to Use the insured unit: ___________________________
4. What portion of the vehicle were damaged? ___________________________________
_______________________________________________________________________

NOTE: For claims reported after the 30-day period from the date of loss, please state the reason
for the late filing of claim.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Accomplished By: ______________________________________

signature over printed name / Date

Relationship with the assured: ____________________________

SICI MAKATI BRANCH

CLAIMS QUESTIONNAIRE