{"text_format":"3","workbook":"xlsx","n_sheets":1,"sheets":["T&T Crit Ill Accid Death"],"not_rendered":{"images":1},"read":"whole","date_system":"1900"}

{"sheet":"T&T Crit Ill Accid Death","index":0,"n_rows":57,"n_cols":16,"rows_kept":57,"merged":[[3,10,3,11],[21,9,21,11],[23,9,23,11],[30,2,30,3],[33,2,33,3],[37,9,37,11],[37,13,37,16],[39,2,39,3],[41,1,41,16],[42,1,42,16],[44,1,44,3],[44,14,44,16],[47,8,47,16],[48,9,48,10],[48,12,48,13],[48,15,48,16]]}
[]
[]
[{"$nulls":8},"Group Policyholder Territory:"]
[{"$nulls":10},"                 Branch:"]
[]
[null,"CLAIMANT'S STATEMENT - CRITICAL ILLNESS/ ACCIDENTAL DISMEMBERMENT"]
[]
[null,"1.  Insured's Name"]
[null,"      If married female, give maiden name also"]
[null,"2.  Insured's Resident Address "]
[]
[null,"3. Insured's Contact Information",{"$nulls":6},"Mobile Number:                                                       Office Number:"]
[null,"Email Address:",{"$nulls":6},"Home Number:"]
[null,"4.  Insured's Employer's Address"]
[]
[]
[null,"5.  a)  Insured's Height"]
[]
[null,"     b)  Insured's Weight"]
[]
[null,"6.  Date illness was first diagnosed.  For dismemberment, date"]
[null,"     accident occurred",{"$nulls":7},"dd/mm/yyyy"]
[null,"7.  Date you stopped performing all occupational duties"]
[{"$nulls":9},"dd/mm/yyyy"]
[null,"8.  Have you done any work since the commencent of this disability?",{"$nulls":7},"o  Yes","If yes, please provide details",null,null,"o  No"]
[]
[]
[null,"9.  Please provide the visitation date(s) and Name and Address of all Physician's consulted by you in relation to your present condition."]
[]
[]
[null,null,"dd/mm/yyyy",null,null,"Physician's details:"]
[]
[]
[null,null,"dd/mm/yyyy",null,null,"Physician's details:"]
[]
[null,null,"Attach separate document including dates and physician's details if more space is required."]
[null,"10.  Have you seen a Physician within the last three (3) years for reasons other than your present condtion?",{"$nulls":11},"o  Yes",null,"o  No"]
[null,"       If yes, please provide details"]
[]
[null,null,"dd/mm/yyyy",null,null,"Physician's details:",{"$nulls":8},"Reason:"]
[]
[null,"The foregoing statements are full and true to the best of my knowledge and belief, and I agree that payment according to the terms of the policy for the period of disability as herein indicated, should be in full satisfaction and discharge of any and all claims, the cause of which originated prior to the date hereof."]
[null,"I hereby authorise: a) any physician, hospital, clinic, insurance company, or other organisation, or person that has any records or knowledge of my family or me, to give to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates any and all information about my family members or me with reference to our finances, our health and medical history and any hospitalization, advice, diagnosis, treatment, disease or ailment.  b) Pan American Life Insurance Company of Trinidad and Tobago, Ltd. and any of its affiliates to provide the information derived from this application and any other existing record, to service providers and related third parties in order to evaluate any insurance proposal request made by me and for the purposes of administration of this policy. c) the disclosure of all information necessary to process this claim to Pan American Life Insurance Company of Trinidad and Tobago, Ltd. affiliates wheresoever located including but not limited to the United States of America and Panama and to such other parties as may reasonably be required to process this claim."]
[null,"____________________________",{"$nulls":3},"__________________",null,null,"_____________________________________",{"$nulls":5},"_____________________"]
[null,"Signature of Insured",{"$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 date of loss"]
[null,"Date of last premium paid if applicable"]
[null,"Amount of last premium paid if applicable"]
[]
[]
[null,"2016-10-16"]