Philippine Heart Center Employees Association - Alliance of Health Workers

Mutual Assistance Application Form

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

A. CLAIMANT INFORMATION

Please fill out the following information.

Date of Filing^*

Membership / Employee ID Number:^*

Service

Unit

First Name:^*

Middle Name:

Last Name:^*

Email Address:

Relationship to the deceased:^*

Spouse

Child (Biological/Adopted/Illegitimate)

Parent

Sibling (Unmarried/Married/Adopted/Illegitimate)

Other (Please specify)

B. DECEASED MEMBER INFORMATION

If claimant is not a member.

First Name^*

Middle Name

Last Name^*

Membership / Employee ID Number:

Date of Death^*

C. REQUIRED DOCUMENTS

Please tick the boxes to confirm submission of the required documents.

1. For the Member^*

Updated Membership Form

Updated Dependent Information Sheet

2. For the Deceased^*

Death Certificate (Original or Certified True Copy)

Marriage Certificate (for Spouse and Step-Parents)

PSA Birth Certificate (for Children or Illegitimate Dependents)

Legal Adoption Documents (for Adopted Children)

D. CLAIM DETAILS

Please fill out the following information.

Type of Claim:^*

First Claim

Repeat Claim (Please specify the number of previous claims):

Amount of Mutual Assistance Sought: ₱^*

E. DECLARATION

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

I hereby declare that the information provided in this form is true and accurate to the best of my knowledge. I also confirm that all the required documents have been submitted and comply with the guidelines of the Mutual Assistance Program. I understand that any false information may result in the denial of my claim.^*

Date of Application:^*

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