Fire Assistance Application Form

Please fill out the following form to submit your Fire Assistance application.

APPLICANT INFORMATION

Please fill out the following information.

Date of Filing^*

Membership / Employee ID Number:^*

Service^*

Unit^*

First Name:^*

Middle Name:

Last Name:^*

Home Address:^*

Mobile Phone Number:^*

Email Address:

FIRE INCIDENT DETAILS

Please provide details about the fire incident.

Date of Occurence:^*

Location of Incident:^*

Extent of Damage: (Please check one:)^*

Moderate Damage (e.g., significant fire damage, temporary displacement)

Severe Damage (e.g., complete destruction of residence, loss of livelihood)

SUPPORTING DOCUMENTS

Please attach the following documents.

List of Documents:^*

Barangay Certification or Government-issued Fire Report

Photos of the Damage (if applicable)

Proof of Residence (e.g., utility bill, ID showing address)

Receipts for Temporary Shelter or Repair Costs (if applicable)

Any other documents supporting your claim

VERIFICATION AND ASSISTANCE REQUEST

Based on the classification of damage.

Total Amount Requested^*

₱

DECLARATION AND AGREEMENT:

Please read the following declaration carefully and tick the checkbox below.

I hereby certify that the information provided in this form is true and correct. I understand that any false information provided may lead to the disqualification of my application. I authorize the PHC Employees Association to verify the information I have submitted, including conducting on-site inspection if necessary. I also acknowledge that I am applying for assistance based on the severity of the fire damage and that approval is subject to the policies and guidelines of the Association's Welfare & Benefit Committee.^*

Date of Application:^*

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