{"text_format":"3","workbook":"xlsx","n_sheets":1,"sheets":["T&T Claimants Stmnt - Death"],"not_rendered":{"images":1},"read":"whole","date_system":"1900"}

{"sheet":"T&T Claimants Stmnt - Death","index":0,"n_rows":54,"n_cols":16,"rows_kept":54,"merged":[[3,10,3,11],[12,12,12,13],[13,9,13,11],[13,12,13,13],[13,14,13,16],[16,12,16,13],[17,9,17,11],[17,12,17,13],[17,14,17,16],[37,1,37,16],[38,0,38,16],[40,1,40,3],[40,14,40,16],[43,8,43,16],[44,9,44,10],[44,12,44,13],[44,15,44,16],[52,1,52,16],[56,1,56,14]]}
[]
[]
[{"$nulls":8},"Group Policyholder Territory:"]
[{"$nulls":10},"         Branch:"]
[]
[null,"CLAIMANT'S STATEMENT - DEATH BENEFIT"]
[null,"Submitted on behalf of:"]
[]
[null,"1.  Insured's Name"]
[null,"      If married female, give maiden name also"]
[null,"2.  Insured's Resident Address at Death"]
[]
[null,"3.  a)  Insured's Date of birth"]
[{"$nulls":9},"                      Day",null,null,"Month",null,"     Year"]
[null,"     b)  Insured's Place of birth"]
[]
[null,"4.  a)  Insured's Date of death"]
[{"$nulls":9},"                      Day",null,null,"Month",null,"     Year"]
[null,"     b)  Insured's Place of death"]
[null,"     c)  Insured's Cause of Death"]
[]
[null,"5.  a)  When did the insured first complain or give other indications"]
[null,"        of last illness?"]
[null,"     b)  When did insured first consult a physician for last illness?"]
[]
[null,"6.  List all Physicians who attended the insured during last "]
[null,"      illness and during three (3) years prior thereto."]
[]
[]
[]
[null,"CLAIMANT'S GENERAL INFORMATION"]
[null,"Claimant's Name"]
[null,"Relationship to Deceased Insured"]
[null,"Address of Claimant"]
[null,"Claimant's Contact Information",{"$nulls":6},"Mobile Number:                                                       Office Number:"]
[null,"Email Address:",{"$nulls":6},"Home Number:"]
[]
[]
["I hereby authorise: a) any physician, hospital, clinic, insurance company, or other organisation, or person that has any records or knowledge of my family or me, to give to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates any and all information about my family members or me with reference to our finances, our health and medical history and any hospitalization, advice, diagnosis, treatment, disease or ailment.  b) Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates to provide the information derived from this application and any other existing record, to service providers and related third parties in order to evaluate any insurance proposal request made by me and for the purposes of administration of this policy. c) the disclosure of all information necessary to process this claim to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. affiliates wheresoever located including but not limited to the United States of America and Panama and to such other parties as may reasonably be required to process this claim."]
[null,"____________________________",{"$nulls":3},"__________________",null,null,"_____________________________________",{"$nulls":5},"_____________________"]
[null,"Signature of Claimant ",{"$nulls":3},"Date (dd/mm/yyyy)",null,null,"      Group Policyholder Representative",{"$nulls":5},"    Date (dd/mm/yyyy)"]
[]
[null,"FOR GROUP POLICYHOLDER USE ONLY"]
[{"$nulls":8},"Complete this section for each credit facilty:"]
[{"$nulls":9},"Facility 1",null,null,"Facility 2",null,null,"Facility 3"]
[null,"Insured's Certificate Number(s) "]
[null,"Effective Date of Coverage "]
[null,"Insured's account balance(s) as of date of death"]
[null,"Date of last premium paid if applicable"]
[null,"Amount of last premium paid if applicable"]
[]
[]
[]
[null,".10/16"]