PHILIPPINE DEPOSIT INSURANCE CORPORATION

PDIC Chino Bldg., 2228 Chino Roces Ave., Makati City 1231
Telephone No. (02) 8841-4141 Toll Free 1-800-1-888-7342 (PDIC) CLAIM FORM
Email : [email protected]
(Please refer to PDC website www.pdic.gov.ph for additional instructions in the filing of claim)

For PDIC Use Only

Name of Bank: ______________________________________________ Bank Code: _________ Date: __________ Claim No.: __________
Branch : ______________________________________________
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: (mm/dd/yyyy) _______________________________________ Spouse’s Name: ______________________________________________________

Sex : Male Female 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
Processed/Signature Verified by : Approved by :
Signature Card Subsidiary Ledger SPA
Duplicate CTD Sec. Cert/Resolution Others ______
Valid ID
ACE/CE Approver
1. ________________ 3. ____________________
2. __________________4. ____________________

Ver. 3 Mar 2023

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 DEPOSIT INSURANCE PAYMENT OPTIONS

Name of Depositor: ___________________________________ Account Number: _________________________

Name of Closed Bank/Branch: __________________________ Signature: _______________________________

FOR PESO ACCOUNT

Please Check ( a) One

Check
A Check payment is issued for payee's account only and for deposit with any local bank.The check is available for
pick up 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 [email protected] 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 Contact numbers

Marital status Face/photo, signature/fingerprints
Name of spouse, if applicable Government identification numbers
Citizenship/nationality Deposit account information
Home address Loan information
Email address 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 All transactions involving closed

claims banks
Loan collection Conduct of customer satisfaction
Verification and settlement of surveys
claims against closed banks 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 [email protected] 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: [email protected]

Page 3 of 3 pages