MortgageClaim

1. Affected party information

Who is submitting this Claim Notice: *

Policy holder
Broker
Advisor
Other

Claimant RUT *

Claimant full name *

Claimant email address *

Claimant phone number *

Insured email address (only if different from the compliant)

2. General information

Loan entity *

Policy number

Policy item

3. Claim information

Damage estimation

Date of loss / Date on which the fact was known *

Time of Loss (if known)

Claims facts *

Affected third parties (if there are any)

4. Address of insured house

Street *

N° *

Address line 2

Municipality *

City *

Region *

5. Authorization for Notification Purposes *

As required by article 30 of Supreme Decree 1055 of the Ministry of Finance, published in the Official Journal on December 29, 2012, I authorize and give express consent to Everest Compañía de Seguros Generales Chile S.A., so that all notifications and communications that are made to the insured, including those that inform about the status of their claim, are made to the email address indicated in this complaint form, constituting the exclusive means of communication for such purposes. This authorization will be valid and will govern unless the Insured objects to this form of notification. In case of opposition, communications must be made by sending a certified letter addressed to the address of the Insured indicated in this claim report, or failing that, to the address registered in the respective insurance policy.

I authorize
I object

6. Processing of Personal Data *

Everest Compañía de Seguros Generales Chile S.A. declares that all information provided by the Insured on the occasion of the reported incident will be handled with absolute confidentiality and for the sole purpose of the analysis required for the settlement of the incident, especially for the evaluation of the origin of coverage and payment of the incident, giving strict and complete compliance with the applicable regulations on the matter. All information provided by the insured in this complaint will be sent to the Liquidator in charge of handling the case, for the purposes of the Liquidation Process. For his part, the Insured gives express consent for this complaint and information associated with it to be sent to the Official Liquidator designated for the settlement of his case, as well as for Everest to process personal data for the purposes and within the scope indicated in this point.

I authorize