REPUBLIC OF THE PHILIPPINES

Department of Finance
INSURANCE COMMISSION
Cebu District Office

_________________________________,
Complainant

IC CEBU CASE No.:

_________________________________

_________________________________,
Respondent,
x---------------------------------------------------x

STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)

1. The personal circumstances of the parties are as follows:

(Ang bawat panig ay ang mga sumusunod)

________________________________ ________ ________ __________________

NAME OF COMPLAINANT/S SEX AGE CIVIL STATUS
(Pangalan ng Naghahabla) (Kasarian) (Edad) (Katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Salong Pagmamay-ari)

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COMPLAINANT’S HOME ADDRESS:
(Pahatirang Sulat sa Bahay ng Naghahabla)

(City) ________________________________________ ___________

(Lungsod) Zip Code

(Province, if applicable) _________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone No. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

NAME OF COMPLAINANT’S REPRESENTATIVE:

_________________________________________________
If applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]

HOME ADDRESS: (City) ______________________________________ ___________

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ________________________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

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________________________________ ________ ________ __________________
NAME OF RESPONDENT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Salong Pagmamay-ari)

RESPONDENT’S HOME ADDRESS:

(Pahatirang Sulat sa Bahay ng Hinahabla)

(City) ________________________________________ ___________

(Lungsod) Zip Code

(Province, if applicable) _________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

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NAME OF RESPONDENT’S REPRESENTATIVE:
_________________________________________________
If applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]

HOME ADDRESS: (City) ______________________________________ ___________

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ________________________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

If more than one (1) respondent, list next respondent here:

(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na hinahabla rito:)

________________________________ ________ ________ __________________

NAME OF RESPONDENT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Salong Pagmamay-ari)

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RESPONDENT’S HOME ADDRESS:
(Pahatirang Sulat sa Bahay ng Hinahabla)

(City) ________________________________________ ___________

(Lungsod) Zip Code

(Province, if applicable) _________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

NAME OF RESPONDENT’S REPRESENTATIVE:

_________________________________________________
If applicable (must be a non-lawyer)
(Pangalan ng Kinatawan:)
(kung meron) [dapat hindi abogado]

HOME ADDRESS: (City) ______________________________________ ___________

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ________________________________________ ___________

(Lalawigan, kung meron) Zip Code

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK: ____________________________________________________________

(Lugar ng Pinagtatrabahuan)

Telephone no. _________________________ Cellphone No. _________________

(Telepono Blg.) (Selpon Blg.)

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*Note: If you need more space, you can write at the back of this Form.
(*Tala: Kung kailangan mo ng karagdagang patlang, maaari mong isulat sa likod ng Form na
ito.)

2. Complainant claims that the respondent denied his/her claim in the amount of ₱ __________.
(Ang Hinahabla ay hindi nagbayad ng claim sa Naghahabla ng halagang)

a) Why does the complainant have a claim against respondent?

(Bakit ang Naghahabla ay may claim laban sa Hinahabla?)
__________________________________________________________________
_________________________________________________________________.
(If you need more space, please use the back page).
(Kung kailangan mo ng patlang, maaaring gamitin ang likod ng pahinang ito.)

b) When did this happen?

(Kailan ito nangyari?)
Date: _________________________
(Petsa)
If no specific date, give the time period:
(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date started: _________________________
(Petsa nagsimula)
Through: _________________________
(Hanggang)

c) How did you compute the claim? (Do not include court costs or fees)
__________________________________________________________________
(Paano mo kinuwenta ang claim?) [Hindi kasama ang bayad sa pagpapatala sa
hukuman.]

3. a) Did you ask the respondent to pay you before you filed this case?
(Siningil mo ba ang Hinahabla bago ka nagsampa ng kasong ito?)
Yes No
(Oo) (Hindi)

If no, explain:
__________________________________________________________________
(Kung hindi, ipaliwanag)

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 b) How did you ask the respondent?
(Paano mo siningil ang Hinahabla?)

In person By phone
(Sa kanya mismo) (Sa telepono)

In writing Others (please specify)_________________

(Sa sulat) (Iba pa) [pakisulat kung paano]

c) When did you do this?

__________________________________________________________________
(Kailan mo ginawa ito?)

4. What is your proof that you have a policy with the respondent?
___________________________________________________________________________
(Ano ang iyong katibayan o pruweba na meron kang policy na inisyu ng Hinahabla?)

5. Did you attach your proof to this form?

(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)

Yes No
(Oo) (Hindi)

6. By the filing of this action, complainant hereby waives any amount in excess of ₱400,000.00,
excluding interest and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang anumang halaga na higit sa
₱400,000.00, hindi kasama ang tubo at gastos sa pagsampa ng kasong ito.)

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 PRAYER
(PAGSAMO)

WHEREFORE, complainant respectfully prays for judgment ordering respondent to pay

the amount of ₱ __________________, with interest at the rate of ___% per annum/per month
from __________________ until fully paid.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na igawad ang
kapasiyahang utusan ang Hinahabla na magbayad sa Naghahabla ng halagang
₱ _____________________, pati ang tubo na ___% bawat taon/ buwan simula
_______________________ hanggang ganap o lubos na mabayaran ito.)
______________________, ____________, 20_____.

______________________________
COMPLAINANT
(Naghahabla)

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