(To be accomplished by the claimant or if unable to do so, by legal guardian or nearest relative)
Policy No. _________________________
Name Date and Place of Birth
1. a. Cause of disability: ( ) Illness ( ) Injury
b. Date and place of commencement of disability __________________________________________________
c. If cause of disability is accident, attach related police report.
2. a. Give complete history of your illness or how injury was sustained: ___________________________________
b. When was the last date you were able to perform your usual work or occupation? ______________________
3. Give names of Physicians, clinic and/or hospitals or other medical facilities where you received treatments prior to
your disability and after your disability for your present illness/injury and indicate inclusive dates:
5. a. If confined to bed at home, indicate inclusive dates _______________________________________________
b. Describe briefly your present daily routine activities _______________________________________________
c. Have you done any work activities after you gave up your usual occupation? If so, please give
d. Has there been any improvement in your condition? If so, please describe: ____________________________
e. When do you expect to return to work?_________________________________________________________
6. Do you have any claim because of your illness or injury against any person or company? If yes,
please give names and their addresses: ___________________________________________________________
I, the undersigned, do solemnly declare that the foregoing answer and statement are full, complete, and true, and I
further agree that the furnishing of this form, or any other forms supplement thereto, by the company, shall not
constitute an admission by it that there is any insurance in force on my life or a waiver of any of its rights or defenses.
Form No. Dis C-001
I hereby authorize any physician, person, hospital or any medical institution, to furnish Generali Pilipinas Life
Assurance Company any information that may be required regarding my illness or injury.
Signature of Witness over Signature of Insured/Payor/Guardian over
Name on Print Name on Print
Subscribed and sworn to before me this____________ day of __________________, 20_____ by the above
claimant who exhibited to me his Residence Certificate No. __________________________________, issued at
________________, on ___________________.
Doc. No. __________:
Book No. __________:
Page No. __________:
Series No. __________: ___________________
Form No. Dis C-001