PHILIPPINE DEPOSIT INSURANCE CORPORATION
PDIC Chino Bldg., 2228 Chino Roces Ave., Makati City 1231
Telephone No. (02) 8841-4141Toll Free: 1-800-1-888-7342 (PDIC)
Email: PAD@pdic.gov.ph
(Please refer to the PDIC website: www.pdic.gov.ph for additional instructions in the filing of claim.)

CLAIM FORM

Please enter your details (fields marked with "*" are required). Click PREVIEW at the bottom of the page to review the accuracy and completeness of data.

Name of Bank:*
Branch:
For PDIC Use Only
Bank Code:Date:Claim No.:
______________________________________________
Type of Depositor:* Individual    Business Entity
Depositor Name:*
(Name of Individual Depositor, Business Name, Name of Registered & Unregistered Association)
Name of Authorized Representative/s (if applicable):
Complete Mailing Address of Depositor/Representative (Do not abbreviate)

House/Building No.
Street Name
Barangay *

Town/City *
Province *
Zip Code
Depositor/Representative Contact Number/s:
Mobile Phone No.:*     Home Phone No.:     Business Phone No.:
Email Address:*
Personal Information (for Individual Depositor Only)
Date of Birth:*
Sex:* Male    Female
Spouse's Name:
Mother's Maiden Name:*

I am the bona fide owner/co-owner of, or agent of the depositor for, the following accounts (the “Account Number”):

*

I hereby file this claim for deposit insurance for the Account. There exists no conflict or dispute arising from my ownership and possession thereof. The Account is my legitimate deposit with the bank.

Under pain of perjury and Section 26 (g) (1) of Republic Act 3591, as amended (filing of fictitious and/or fraudulent claim for deposit insurance), I hereby certify to the truth and accuracy of my statements herein, as well as all information and documents I have provided PDIC. I hereby authorize PDIC to verify or confirm with the appropriate issuing agency/agencies the authenticity of any and all documents I submitted.

I hold myself liable to any person, natural or juridical, who may be prejudiced by my representations, and I undertake to hold them free and harmless from any and all liabilities, civil or criminal, that may arise from these representations. I hereby undertake to immediately refund PDIC, through its duly authorized officers and employees, without need of demand, the amount paid to me by way of deposit insurance including interest thereon in the event of excessive and undue payment, due to any of my representations or declarations, or in case of payment made through mistake or inadvertence, or payment which, in the course of audit, is disallowed under COA rules and regulations. I further undertake to indemnify PDIC, the bank and/or third parties for any loss or damage occasioned by such payment. I hereby release and discharge PDIC from any and all obligations in connection with this claim.

I understand that this deposit insurance claim shall also serve as my claim against the bank for any portion of the Account not covered by deposit insurance, provided that this is filed within sixty (60) days from the date of publication of the notice of bank closure.

By affixing my signature, I also acknowledge to have read and understood the contents of the Privacy Notice included in the Claim Form.

IN WITNESS WHEREOF, I have hereunto set my hand on the day and at the place written below.

___________________________________________________________________
Signature of Depositor/Claimant (Authorized Representative/s) over Printed Name

SUBSCRIBED AND SWORN TO before me in __________________________, this _____ day of ______________, by affiant who has satisfactorily proven his/her identity through his/her _________________________ issued on _____________________ in ____________________________.

Notary Public/Claim Examiner

Doc. No. __________ ;
Page No. __________ ;
Book No. __________ ;
Series of __________.

Computation of Insured Amount (For PDIC Use Only)
Account Name Type/Account No. Adj. Balance Excess Net Insured





TOTALS:
Signature Verified Against: No Specimen Signature Card
Signature Card
Duplicate CTD
Valid ID 		Subsidiary Ledger
Sec. Cert/Resolution
 SPA
Others __________
1. _______________________ 2. _______________________
3. _______________________ 4. _______________________

  Processed/Signature Verified by:

____________________________
ACE/CE


  Approved by:

____________________________
Approver

Ver. 3 Mar 2023
Page 1 of 3 pages

DEPOSIT INSURANCE PAYMENT OPTIONS
Name of Depositor:
Name of Closed Bank/Branch: 		Accout Number:
Signature:
FOR PESO ACCOUNT
Please Check One
Check
A Check payment is issued for payee's account only and for deposit with any local bank. The check is available for pickup by the depositor or a duly authorized representative with SPA at PDIC or may be sent through registered mail delivered to addressee only.
Note: For Business Entity, the only available payment option is CHECK for payee's account only.
Cash Over the Counter (COTC) at the Land Bank of the Philippines (LBP)
COTC is CASH payment disbursed by a designated LBP Servicing Branch to depositor only.
Credit to depositor's existing bank account
A secured electronic fund transfer directly credited to depositor's existing personal bank account. Corresponding bank charges may be imposed.
Name of Bank:
Account Name:
Account Number:
Electronic Money Issuers (EMIs)
Deposit insurance payment will be transferred through GCash, Paymaya, or DCPay. To opt for the EMI, the account should be registered in the name of the depositor and the limit should be able to accommodate the amount of insurance payment to be transferred to the EMI account.
This is subject to the transaction limits set by the EMIs.
GCash Account Name: Account Number:
PayMaya Account Name: Account Number:
DCPay Account Name: Account Number:
LBP Cash Card
The Cash Card is a stored value card containing the amount of the insured deposit which can be withdrawn via Automated Teller Machine (ATM). It has a combination functions of debit card and an ATM. Depositor can withdraw with any bank. The PIN Mailer and the Cash Card are released directly to the depositor through personal pick up at PDIC.
OUTGOING TELEGRAPHIC TRANSFER (OTT) - Recommended for depositors residing abroad
The OTT is the remittance of insured deposit payment to depositor's dollar account abroad. Depositors to coordinate with PDIC thru CSD@pdic.gov.ph for the requirements. Bank charges imposed by the bank will be for the account of the depositor.
FOR FOREIGN CURRENCY ACCOUNT
US Dollar (USD)
Deposit insurance payment in dollar will be released by a designated Land Bank Servicing Branch to be personally claimed by the depositor.
Philippine Peso (PhP)
Depositor may opt to be paid in Philippine Peso. Please refer to options under Peso Account. Conversion rate shall be based on the prevailing rate as of the closed bank takeover date.

Page 2 of 3 pages

PRIVACY NOTICE

The PDIC is committed to ensure that your personal data are protected and secured. We only use your personal data for the purpose of providing services pursuant to our mandate. Our privacy policy values and protects your personal data under the Data Privacy Act of 2012.

We collect any or all of the following personal data from you when you submit to us your deposit insurance claims, complaints, inquiries or requests through various modes (phone, mail, email, social media and personal submission) or when we take custody of records of closed banks as statutory receiver:

Full name
Marital status
Name of spouse, if applicable
Citizenship/nationality
Home address
Email address
 Contact numbers
Face/photo, signature/fingerprints
Government identification numbers
Deposit account information
Loan information
Any other personal data collected
as may be applicable

Personal data collected or processed is used only for the following purposes:

Settlement of deposit insurance
claims
Loan collection
Verification and settlement of
claims against closed banks 		All transactions involving closed
banks
Conduct of customer satisfaction
surveys
Such other purpose/s as may be
applicable

Personal data may be shared with other government offices as required by law or lawful order, or for the purpose of performing a public function, or providing public service. The sharing of personal information with other government agencies is subject to the adoption of adequate safeguards for data privacy and security as embodied in a sharing agreement.

Only authorized PDIC personnel has access to these personal information. Physical and digital records of personal data collected will be stored in accordance with the retention periods as provided under existing rules and regulations but in no case shall retention be longer than necessary to achieve its purpose. After such periods, they shall be disposed of through the applicable methods for destruction as provided under existing guidelines.

You may request for a copy of any personal data we hold about you and to ask for its correction or revision if you think it is inaccurate or incomplete.

If you have any request regarding your personal data or suggestion to our privacy notice, please email us at pad@pdic.gov.ph or contact us at (02) 8841-4630/1-800-1-888-7342.

You may also contact our Data Protection Officer thru the following:

Address: 2nd Floor, PDIC Chino Building
2228 Chino Roces Avenue
Makati City 1231, Philippines
Tel. No.: (02) 8841-4302
Email: dpo@pdic.gov.ph



Page 3 of 3 pages