FPG Insurance

GCASH USER INFORMATION

LAST NAME *

FIRST NAME *

MIDDLE NAME *

SUFFIX

HOME ADDRESS *

E-MAIL ADDRESS *

MOBILE NUMBER *

AGE *

ACCIDENT INFORMATION

DATE OF ACCIDENT *

TIME OF ACCIDENT *

PLACE OF ACCIDENT *

STATE PRECISELY HOW THE ACCIDENT OCCURED *

NATURE & EXTENT OF INJURIES *

HOSPITAL CONFINEMENT INFORMATION

STATE THE NUMBER OF DAYS YOU HAVE BEEN CONFINED IN THE HOSPITAL BY THE DIRECTION OF YOUR MEDICAL ATTENDANT

CONFINED TO THE HOSPITAL FOR

NUMBER OF DAYS

FROM

PROVIDE THE NAME AND ADDRESS OF THE DOCTOR OR PHYSICIAN WHO IS OR HAS BEEN ATTENDING TO YOU FOR THIS INJURY

HAS HE OR ANY OTHER PRACTITIONER ATTENDED TO YOU PREVIOUSLY FOR ANY ILLNESS OR INJURY?

YES

UPLOAD DOCUMENTS

PERSONAL ACCIDENT FORM B

POLICE REPORT/INVESTIGATION REPORT

MEDICAL CERTIFICATE

HOSPITAL STATEMENT OF ACCOUNT/CHARGE SLIPS

ORIGINAL OFFICIAL RECEIPTS OF HOSPITAL BILLS/PROFESSIONAL FEES

PROOF OF BENEFICIARY'S IDENTITY LIKE BIRTH CERTIFICATE, MARRIAGE CONTRACT (ORIGINAL)

ORIGINAL COPY OF DEATH CERTIFICATE

OTHERS (I.E. AUTOPSY REPORT, MEDICO-LEGAL REPORT, PICTURES, NEWSPAPER CLIPPINGS)

Declaration

I HEREBY DECLARE, THAT I HAVE RECEIVED THE INJURIES ABOVE DESCRIBED BY VIOLENT, ACCIDENTAL, EXTERNAL AND VISIBLE MEANS, AND I CLAIM COMPENSATION UNDER THE ABOVE POLICY IN RESPECT THEREOF. I HEREBY WARRANT THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT I HAVE NOT WITHHELD FROM THE COMPANY ANY MATERIALS INFORMATION IN CONNECTION WITH THIS CLAIM.

I have read and understood and voluntarily agreed to the collection, use, and disclosure of my personal data in accordance with FPG Privacy Policy.