Death Claim Form

Republic of the Philippines
Province of Bohol
Municipality of Candijay
OFFICE OF THE BARANGAY CAPTAIN
Barangay Lungsodaan

INDORSEMENT
(Death Claim)



GOVERNOR ERICO B. AUMENTADO
Thru: The Officer-in-Charge
The Governor’s Aid Personal Accident Insurance
Barangay Affairs


Sir:

This is to attest that the death of MELQUIADES P. ANIASCO, SR. who had been serving as a member of the Lupong Tagapamayapa of Barangay Lungsodaan was caused while in the performance of his duty / aggravated solely by the performance of his work as such Barangay Officials on July 20, 2008 at Candijay, Bohol, Philippines.

This is to further certify that this claim for death benefits of his legal heirs is valid and legitimate.

Issued this 4th day of August, 2008 at Candijay, Bohol, Philippines.



JIMMY D. BUSANO
Barangay Captain



SUBSCRIBED AND SWORN to before me this _____ day of August, 2008 at Candijay, Bohol, Philippines.



HON. SERGIO G. AMORA, JR.
Administering Officer
Municipal Mayor




Barangay Lungsodaan, Candijay, Bohol
August 4, 2008

APPLICATION FOR DEATH / MEDICAL CLAIMS

GOVERNOR ERICO B. AUMENTADO
Thru: The Officer-in-Charge
The Governor’s Aid Personal Accident Insurance
Barangay Affairs

Sir:
This is to respectfully file my claim for death / medical benefits as insured / legal heirs of MELQUIADE P. ANIASCO, SR. a member of the Lupong Tagapamayapa of Barangay Lungsodaan, Candijay, Bohol, covered under the Governor’s Aid Personal Accident Insurance.


• Date of Death : July 31, 2008 • Caused of Death: Sepsis secondary to community acquired pneumonia, severe.
• Complete mechanical large bowel obstruction secondary to sigmoid mass, R/I malignancy.

• Date of Injury: July 20, 2008 • Nature of Injury: Medical
• Date of Medical Confinement:: July 20, 2008 to July 31, 2008 at the Gov. Celestino Gallares Memorial Hospital, Miguel Parras St. Tagbilaran City.

Thank you very much in anticipation of a prompt and appropriate action on this application.

Truly yours,

ALEJANDRA O. ANIASCO
Applicant


SUBSCRIBED AND SWORN to before me this _____ day of August, 2008 at Candijay, Bohol, Philippines.


HON. SERGIO G. AMORA, JR.
Administering Officer
Municipal Mayor