We would like to help you with your claim application. Please fill out the form below and complete all fields marked with (*).

Before submitting your application, please prepare the following documentation for your convenience in the next steps.

1. Medical Certification informing of permanent disability

2. Hospital Bill

3. Medical Records (laboratory results, Medical History, Abstract, etc.) during first confinement and recent medical check up

4. Police Report

5. Photocopy of Valid IDs of Planholder (Government-issued ID’s)

LPA Number:*

Claimant's First Name:*

Claimant's Middle Initial:*

Claimant's Last Name:*

Mobile Number:*

Email Address:*

Cause of Disability:*

Date of Disability:*

Previous Medical Condition:

Date of Medical Certificate:*

Relationship to the Planholder:*

Medical Certification*

Hospital Bill*

Medical Records*

Police Report*

Photocopy of Valid IDs of Planholder*