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Claim Form

Member Information

Last Name

First Name

Middle Name

Suffix

Date of Birth

Email Address

Member or claimant/beneficiary email address

Verify Email Address

Enter the same email address provided above

Contact Details

Street

Barangay

Town/ District

City/ Municipality

Type the first few letters of the city or municipality and select from the search results

Zip Code

Telephone No.

Provide numbers only. Spaces, dashes, and other characters are not allowed.

Cellphone No.

Provide numbers only. Spaces, dashes, and other characters are not allowed.

Personal Details

Civil Status

Name of Beneficiary

In case of member's death, provide the name of a family member in accordance with Philippine inheritance and succession laws.

Beneficiary address same as member

Address

Claim Details

Fund Type

Reason for Claim

Date of Death

Specify date if reason for claim is death

Bank Details

Name of Bank

Branch

Bank Account No.

Bank Account Name

This field is automatically set to the name of the member. In case of death as reason for claim, the name of the beneficiary is used.

Declarations

I agree to the terms and conditions set forth

I confirm that all details provided to be true and accurate

I hereby authorize that Associated Marine Officers' and Seamen's Union of the Philippines (AMOSUP) to collect and process the personal data collected

I hereby confirm that the three (3) specimen signatures represent my agreement with your terms and conditions