{"text_format":"3","workbook":"xlsx","n_sheets":2,"sheets":["T&T Claimants Stmnt - Death","T&T Physicians Stmt_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"]

{"sheet":"T&T Physicians Stmt_Death","index":1,"n_rows":61,"n_cols":15,"rows_kept":61,"merged":[[8,1,8,14],[59,1,59,14]]}
[]
[]
[]
[]
[]
[null,"PROOF OF DEATH",{"$nulls":9},"No. 2 PHYSICIAN'S STATEMENT"]
[null,"Submitted to:"]
[]
[null,"The Medical certification follow the recommendations of the World Health Assembly made in Geneva on July 24, 1948.\nAll answers must be in the Physician's handwriting.\nIn the interest of accurate vital statistics, please conform to the international List of the Causes of Death."]
[]
[null,"Full name of deceased",{"$nulls":6},"Date of Death"]
[]
[null,"Residence at death",{"$nulls":6},"Place of Death (if Hospital or Institution, provide name)"]
[]
[null,"Age at death or date of birth"]
[]
[null,"Cause of death (Enter only one cause for each of a, b, and c.)",{"$nulls":9},"Interval between onset and death"]
[]
[null,"Disease or condition directly leading to death: (this does not mean the mode of "]
[null,"dying, such as heart failure, anesthesia etc.  It means the disease, injury or"]
[null,"complication which caused the death)."]
[]
[null,"(a)",{"$nulls":9},"(a)"]
[]
[null,"Antecedent causes.  (Morbid conditions, if any, giving rise to the above cause (a) "]
[null,"stating the underlying cause last)."]
[]
[null,"Due to (b)",{"$nulls":9},"(b)"]
[]
[null,"Due to (c)",{"$nulls":9},"(c)"]
[]
[null,"Other significant conditions: (Contributing to the death but not related to the disease or condition causing death)"]
[]
[]
[null,"Date of First Attendance in",{"$nulls":6},"Date of Last Attendance in"]
[null,"Last Illness",{"$nulls":6},"Last Illness"]
[null,"If death was due to accident, suicide or homicide, specify which and",{"$nulls":6},"Was an inquest held?",{"$nulls":4},"o Yes","o No"]
[null,"describe briefly."]
[{"$nulls":8},"Was an autopsy performed?",{"$nulls":4},"o Yes","o No"]
[]
[null,"Were there any identification marks on the body?",{"$nulls":4},"o Yes","o No","If so, by whom and with what findings?"]
[null,"If \"Yes\", give particulars"]
[]
[null,"Have you treated or advised the deceased during the last five (5) years, prior to the last illness?",{"$nulls":11},"o Yes","o No"]
[]
[null,"Did the deceased, to your knowledge, receive treatment during the last five (5) years from any other physician,",{"$nulls":11},"o Yes","o No"]
[null,"or in any Hospital or Institution?"]
[null,"If yes to either question, please furnish the following:"]
[]
[null,"Name",{"$nulls":3},"Address",null,null,"Nature of Illness or Injury",{"$nulls":4},"Dates"]
[]
[]
[null,"THESE STATEMENTS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF"]
[]
[]
[null,"Signature M.D.",{"$nulls":3},"Address",{"$nulls":7},"Date"]
[]
[]
[]
[null,"Pan-American Life Insurance Company of Trinidad and Tobago, Ltd.\n91-93 St. Vincent Street  Port of Spain, Republic of Trinidad & Tobago  Tel: 868.625.4426  Fax: 868.623.4923  palig.com"]
[null,".10/16"]