Deceased Notification
Member Details:
Name of Deceased Member
*
Last Name
First Name
Middle Name
Date of Death
*
-
Month
-
Day
Year
Date
Cause of Death
*
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Scanned copy or picture of Death Certificate or Barangay Certificate
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Claimant Details:
Name of Claimant
*
Last Name
First Name
Middle Name
Relationship to Deceased Member
*
Contact Number/s
*
E-mail Address
*
Sa pamamagitan ng pagsagot sa form na ito, ay nagbibigay ka ng pahintulot para sa St. Martin Coop na itala at i-proseso ang iyong personal na impormasyon para lamang sa services claim na ito alinsunod sa Data Privacy Act of 2012 (RA10173) at implementing rules and regulation nito
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