GLOBE GADGET CARE CLAIM FORM Important Information 1. In order to submit your claim, please complete the relevant sections. This first page must be completed for all claims. The privacy consent must be completed for all claims. 2. The supporting documentation required for your claim is detailed below each section. 3. Before completing this form, please read the conditions of the policy. 4. The Insured shall exercise due diligence and take all reasonable precautions to protect the Equipment against Theft or Damage and comply with requirements and manufacturer s recommendations. 5. Unless otherwise stated in the policy, the claim benefit on any device is the cost of repair or a like-for-like replacement device as determined by ACE Insurance. 6. CASH SETTLEMENTS WILL NOT BE MADE. The issuance and acceptance of this form does not constitute an admission of liability by ACE Insurance or a waiver of its rights. Policy and Claimant Details Name of Claimant (Mr/Mrs/Ms) Date of Birth Occupation Address (Unit/House No., Street, Brgy/Town, City) Postcode Tel. No. (House) (Business) (Mobile) - - - - Email Address Policy No. Insured Device (Make and Model) Where did you purchase your device? What date did you purchase the insured device? What is the original purchase invoice number? / Insured device mobile number (if applicable)? Insured device IMEI/serial number (if applicable)? - - If claim is approved, please select preferred day of (replacement device) delivery: Monday Wednesday Friday Insurance Company of North America 24th Floor, Zuellig Building, Makati Avenue corner Paseo de Roxas, Makati City 1226 Philippines Tel: (632) 756 5400 Domestic Toll Free: 1-800-8-756 5400 Fax: (632) 325 1669 Email: globeconsumerclaims.ph@acegroup.com www.acegroup.com Page 1 of 6
Section 1- Accidental Damage Claim DOCUMENTS REQUIRED FOR CLAIMS PROCESSING* - Any document or proof of payment of Outstanding Balance of Globe Account covering claim period - Photo of the damaged phone - Notarized Affidavit of Ownership and Loss with Undertaking (NTC Form for Handset Blocking) o for phones which cannot be retrieved i.e. dropped in the sea during boat ride *Note that failure to provide these documents may result in claims processing delays. 1. Please provide details of how the damage occurred 2. Time of damage 3. Date of damage 4. Place of damage : am pm 5. Where was the device at the time of the incident? 6. Who is your mobile phone network operator? 7. Have you reported the incident to your network operator? Yes No If YES: Date reported to network operator 8. Please describe the damage to, or the fault with, your device: (e.g. screen is blurred, device is not turning on, etc.) 9. Are you the sole owner of the damaged device? Yes No 10. Is the damaged device covered by any other insurance? Yes No If YES: Which Company? Policy No.: 11. Is the device still under warranty? Yes No 12. In the last 3 years, have you ever made a claim with another insurer in respect of damage for anything that is covered under this policy? Yes No If YES, please provide details: Page 2 of 6
Section 2- Theft Claim DOCUMENTS REQUIRED FOR CLAIMS PROCESSING* - Any document or proof of payment of Outstanding Balance of Globe Account covering claim period - Original copy of Police Report - Notarized Affidavit of Ownership and Loss with Undertaking (NTC Form for Handset Blocking) *Note that failure to provide these documents may result in claims processing delays. 1. Please provide details of how the theft occurred 2. Time of theft 3. Date of theft 4. Place of theft : am pm 5. Where was the device at the time of the theft? 6. Who is your mobile phone network operator? 7. Have you reported the incident to your network operator? Yes No If YES: Date reported to network operator 8. Have you reported the theft to the police? If YES: Date reported to the police: Name of police station theft was reported to: Police Reference No. If NO: Please state reason why: 9. Are you the sole owner of the stolen device? Yes No 10. Is the stolen device covered by any other insurance? Yes No If YES: Which Company? Policy No.: 11. In the last 3 years, have you ever made a claim with another insurer in respect to theft? Yes No If YES, please provide details: Page 3 of 6
Section 3- Bill Protect Benefits If injury: Time of Accident Date of Accident Nature of Injury (e.g. fracture, cut, bruise, etc.) : am pm Explain exactly how the accident occurred If sickness: Date symptom first noticed Nature of illness (describe the symptoms suffered) If hospitalized: Name of hospital Address of hospital Period of hospitalization: From To Date of first consultation with a medical practitioner for this condition: Name of Physician or Surgeon Address of Physician or Surgeon Details of Temporary Disability When did you cease work? If illness, house confinement date When did or will you resume any part of your work? All work? Describe fully the duties of your occupation Are you claiming from any other insurance company or other sources in respect of injury/illness? Yes No If YES, please provide: Name of Insurance Co. Policy No. Date insurance affected Amount of benefits,,. Page 4 of 6
Attending Physician's Statement Name of Patient Date of Birth Primary Diagnosis Patient's sex: Male Female Secondary Diagnosis Period of hospitalization From To Complete admitting history Past medical history: Date of diagnosis Medical condition: Patient physical examination findings: Significant diagnostic procedure findings: Date of services: Place of services: Description of surgical or medical services rendered/procedure: Date of services: Place of services: Description of surgical or medical services rendered/procedure: Is condition due to injury or sickness arising out of patient s employment? Yes No Is condition due to injury or sickness arising out of patient s pregnancy? If YES: approximate date pregnancy commenced: Date symptoms first appeared or accident happened: Date condition was diagnosed: Date patient first consulted you for this condition: Has the patient ever had the same or similar condition? Yes No If YES: please state when Details of the condition Were registered private duly nurse (R.N.) services necessary? Yes No From To Patient was continuously disabled: Patient was partially disabled: Patient was house confined: If still disabled, date patient should be able to return to work: I hereby certify that I have personally examined and treated the patient for the above injury/sickness and that the facts as given above present my opinion of his/her condition. Official Address: Signature: Tel. No.: Name of Physician: Email Address: License No.: PTR No.: Date: Partial disablement arises when the claimant is only slightly injured or has so far recovered from injuries as to be capable of attending to some portion of his or her ordinary profession, business or occupation. Permanent total disability means disablement which, having lasted for at least 12 consecutive months, will, in all probability, entirely prevent the insured person from engaging in gainful employment of any and every kind for the remainder of his or her life. Page 5 of 6
Privacy Consent - Claim Assessment Protection of My Privacy Acknowledgement and Consents By signing this form, I agree that ACE Insurance will use the information supplied during the formation and performance of my policy for policy administration, customer services, paying claims and fraud prevention. ACE Insurance may disclose this information to its service providers and its agents for these purposes. ACE Insurance will keep this information for a reasonable period. Where sensitive personal data has been disclosed, including any criminal record information, ACE Insurance will also use this information for the above purposes. ACE Insurance may also transfer certain information to countries that do not provide the same level of data protection for the above purposes so a contract will be in place to ensure the information transferred is protected. Individuals whose information has been supplied to ACE Insurance have a right to ask for a copy of that information and to have any inaccuracies corrected. ACE Insurance may record telephone calls to make sure it follows instructions correctly and for staff training purposes. When personal or sensitive data is supplied to ACE Insurance about third parties other than the Insured, both during the formation and performance of this policy, ACE Insurance assumes that those third parties consent to the supply of this information to ACE Insurance, to ACE Insurance processing this data, including sensitive personal data, and to the transfer of their information abroad. ACE Insurance will also assume that the supplier of the information is authorized to receive, on their behalf, any data protection notices. I declare that, I understand that by investigating my claim or by accepting proof of my claim, ACE Insurance has made no acceptance of liability, or waived any of its rights in defense of any claim arising under the policy. I agree to ACE Insurance using and disclosing my personal information pursuant to ACE's Privacy Policy and this document. In the event of any conflict between the documents, this document will be determinative. This consent remains valid unless I alter or revoke it by giving written notice to ACE Insurance. I authorize any person or entity, including but not limited to the parties referred to above, to provide to ACE Insurance such personal information as ACE Insurance in its absolute discretion considers relevant for its assessment of my claim. I confirm that any information that I supply will be true and correct and that I will not withhold any information likely to affect the acceptance or handling of my claim. I understand that my claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts. I appoint ACE Insurance to do everything necessary or expedient to give effect to the transactions contemplated by the consents and authorizations in this document and to execute, on my behalf, any documents or to do such acts required to give effect to this Privacy Consent. Signature: Name of Claimant: Date: 2015 ACE Group. Coverages underwritten by one or more companies of the ACE Group. Not all coverages available in all jurisdictions. ACE, ACE logo, and ACE insured are trademarks of ACE Limited. 01/15/V1 Page 6 of 6