STARR INTERNATIONAL INSURANCE PHILIPPINES BRANCH is committed in protecting your personal data privacy. Presented below is an overview of our practices in careful handling of your personal information.

Starr gathers your personal information (which may include sensitive information) in order to establish all necessary details that will assist us in the proper handling and evaluation of your claim. Personal information may be obtained by us directly from you or via a third party such as your insurance intermediary (i.e. agent or broker) or employer (in case of group insurance policy

When the information is provided to us via third party, we use that information on the basis that you have consented or would reasonably expect us to collect your personal information in this way and ensure that you will be made aware on our practices in handling your personal information.

The main purpose for our collection and use of your personal information is to make sure that appropriate and fair evaluation of claim will be delivered toyou in accordance with the terms, conditions and provisions of your insurance policy. All reasonable precautions are carefully taken to protect this personal information and being treated with utmost confidentiality.

We may disclose the information we collect to third parties, including service providers engaged by us to undertake certain claims procedures such as investigation and verification on our behalf. In some circumstances, we may need to transfer personal information to other entities within the STARR Group of Companies (such as our regional office at Hongkong, USA and other countries) or third parties with whom we, or those other STARR Group entities, have sub-contracted to provide specific services for us which may be outside of the Philippines.

In all instances where personal information may be disclosed overseas are for claims related only, in addition to any local data privacy laws, all reasonable precautions are carefully taken and strict measures are in place to ensure that those parties hold and use that information in accordance with the consent you have provided and in accordance with our responsibilities to you under the DATA PRIVACY ACT OF 2012.

Please be informed that you have an option to withdraw your consent by providing us your written notice, however, it is important for you to understand that this may mean that we may not be able to respond favorably to any claim.

FRAUD WARNING

Section 251 of the Insurance Code, as amended, imposes a fine not exceeding twice the amount claimed and/or imprisonment of two (2) years, or both, at the discretion of the court, to any person who presents or causes to be presented any fraudulent claim for the payment of a loss under a contract of insurance, and who fraudulently prepares, makes or subscribes any writing with intent to present or use the same, or to allow it to be presented in support of any claim (IC Circular No. 2016-50

IMPORTANT INFORMATION

1. Please complete the claim form in BLOCK CAPITALS and fill-up all the required information in this form truthfully and accurately. If the space is not enough or no applicable field is available, please supplement information by attaching a separate sheet; 2. Acceptance of this form must not be construed as an admission of liability on the part of Starr International Insurance Philippines Branch; 3. We may require submission of additional document/s, as needed.

SECTION A: POLICYHOLDER AND INSURED PERSON INFORMATION

SECTION B: TYPES OF CLAIMS AND AMOUNT

If YES, please provide below information.

SECTION E : DECLARATION AND AUTHORIZATION

• The undersigned hereby declares that to the best of my/our knowledge and belief, the above statement and particulars are fully and truly made;
• I/We agree that if any fraudulent means or devices are used in connection with obtaining any benefit under the Policy, the Policy shall be void against me/us;
• I/We agree that any of my/our personal information collected or held by Starr International Insurance Philippines Branch ("STARR") or its authorized representatives is provided and will be held, used and disclosed by STARR to individuals/organization associated with STARR or any selected third party for the purpose of processing the claims herein, providing data matching and to communicate with me/us for such purposes. The undersigned understand that STARR may not be able to process the claims herein if I/we fail to provide any information requested in this Claim Form. The undersigned further understand that I/we have the right to obtain access and to request correction of my personal information held by STARR. Such request can be made to STARR's Operations Officer-In-Charge at Unit 5, Tower 2, 23/F, The Enterprise Center, 6766 Ayala Avenue corner Paseo de Roxas, Legaspi Village, Makati City, Philippines.
• I/We hereby irrevocably authorize STARR or its authorize representative to obtain my/our medical records from my/our treating physicians, hospitals, clinics, insurance companies, government agencies or other relevant organizations in relation to the accidemt or claim. This authorization is valid even I/we am/are deceased. My/our next-of-kin is/are bound by this authorization. The original or copy of this authorization has the same effects.

I hereby agree and authorize Starr International Insurance Philippines Branch to pay benefit due in respect of this claim to:

To facilitate processing of your claim, please submit the Duly Accomplished Personal Accident Claim Form together with the required supporting documents listed below. Acceptance of this form must not be construed as an admission of liability on the part of Starr International Insurance Philippines Branch. We reserve the right to request for additional information or document, if necessary.

ACCIDENTAL MEDICAL EXPENSES & PERMANENT DISABLEMENT:

1. All original medical invoices and receipts;

All original medical invoices and receipts;

2. All hospital & medical records detailing the diagnosis and treatment received;

3. Medical specialist report on sustained permanent disability, if applicable:

4. Incident Report issued by the competent authorities with findings on the alleged accident;

5. Copy of at least two (2) valid government IDs with three (3) specimen signatures;

6. Copy of Driver's License if driving at the time of the accident;

7. Photograph of insured (in amputation cases).

ACCIDENTAL DEATH:

1. All original medical invoices and receipts;

2. All hospital & medical records; 

3. Medical specialist report certifying death;

4. Incident Report issued by the competent authorities with findings on the alleged accident; 

5. Copy of at least two (2) valid government IDs of the deceased; 

6. Copy of Driver's License if driving at the time of the accident; 

7. Certified True Copy or NSO Certified Death Certificate; 

8. Original Official Receipts for Burial Expenses; 

9. NSO Certified Copy of Birth Certificate of the Insured

10. Proof of Beneficiary

a. IF MARITAL STATUS OF DECEASED IS SINGLE:

NSO Certified True Copy of Certificate of No Marriage, NSO Certified True Copy of the Marriage Certificate of the Surviving Parents, Copy of the Valid Government ID of Both Surviving Parents, Copy of the Valid Government ID of Both Surviving Parents;

b. IF MARITAL STATUS OF THE DECEASED IS MARRIED:

NSO Certified True Copy of the Marriage Certificate,
Copy of the Valid Government ID of the Surviving Spouse,
Copy of Birth Certificate of Surviving Children

c. IF SURVIVED BY OTHER RELATIVES:
Please indicate relationship of the surviving relative with the
deceased so we could inform you of the documents needed.