1/2

Universal Claim Declaration Format

NOTE: It is important that this form is filled out in a single ink, with printed and legible letters. That all questions are
answered and that truthful, complete, and detailed information is provided. By submitting this form, the company
is not obligated to admit the validity of the claim, nor to waive the rights reserved under the Policy
And/or Law on the Insurance Contract. This procedure is completely free of charge.
policy_number Certificate No. Place and date:
Type of complaint: Death Total and permanent disability Others Specify: ________________
By filling out this form, a formal complaint is filed with Seguros Monterrey New York Life, S.A. de C.V.
coverage of the above-mentioned policy(ies)
Insured Data
Paternal Surname Maternal Surname Name(s)

Dateofbirth Nationality Country of birth

Day Me Year

RFC (with homoclave) or CURP SerialnumberofthedigitalcertificateoftheElectronicSignature

Advanced(FIEL)(onlyifyouhaveit)

(street and exterior and interior number) Postal Code Colony

Town Hall or Municipality City State

Phone (include area code) Email

Last occupation or profession Activity or line of business of the place where he/she performs or used to perform his/her
occupation or profession
Describe what the cause of death was, accident or illness:

Briefly describe the work or professional activities you performed or were performing before the event that triggered the claim:

Place and/or address where he/she performs or performed his/her occupation or profession

Date of the death, accident, or when the first symptoms of the disease appeared:
Beneficiary Data
Name(s) or Business Name Father's Last Name Maternal Surname

Nationality Date of birth or date of incorporation Country of Birth or Constitution

RFC (with verification key) or CURP Occupation or Profession

Turnover or business activity Business name or corporate name Email

Phone (include area code) (street and exterior and interior number) Zip Code

Colony Mayor's office or Municipality City State

Commercial Registry (For Legal Entities Only) Serial number of the digital certificate of the Electronic Signature
Advanced (FIEL) (only if you have it)
Full name of the legal representative:
Nationality Date of birth
 2/2
Data for Transfer
Bank ______________________ CLABE Account (18 digits) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
I expressly declare that when making the payment through the delivery of the check or by electronic bank transfer to
the account designated by the undersigned, for the amount that corresponds according to the obligations agreed in the contract of
Sure, I will consider the payment recognized and fulfilled to my complete satisfaction, with which I acknowledge that the Insurer fully provides
fulfillment of the obligations assumed by her.
By virtue of this, from this moment I grant the broadest release that is legally appropriate in favor of Seguros Monterrey.
New York Life, S.A. de C.V., reserving no right or action to exercise against that Institution or third party.
person who could derive from the Insurance Contract under the mentioned policy. Furthermore, from this
I hereby assume any obligation that may arise before third parties as a result of the aforementioned payment, so
I force myself to safely and peacefully release Seguros Monterrey New York Life, S.A. de C.V. from any claim that may arise.
to present any person who had opposing interests regarding the aforementioned payment, absolving everyone
the legal effects to which Seguros Monterrey New York Life, S.A. de C.V. may be subject. This document serves as formal
desistment before any authority, obligating me to ratify it at the moment I am required, stating that it is
grants free from any coercion, harm, error, fraud or any vice of will.
I finally authorize Seguros Monterrey NewYork Life, S.A. de C.V. to issue a nominal check in favor of the undersigned.
in the event that for any reason beyond your control you are unable to make the bank electronic transfer to the
designated account.
Important to read before signing
I accept that Seguros Monterrey NewYork Life, S.A. de C.V. in terms of the Federal Law on Personal Data Protection in
Possession of Individuals provided me with their Privacy Notice, which I declare to know and accept in all its terms.
I was informed about the availability of said Notice and its updates on the page www.mnyl.com.mx/aviso-de-privacidad.aspx
I expressly authorize Seguros Monterrey NewYork Life, S.A. de C.V. to process and transfer my personal data that
are included in the present format, including financial or asset data and sensitive personal data, especially
that information related to my health and the health of the data subjects listed herein
request, in accordance with the terms of this consent and the primary purposes described in the Notice of
Privacy of Seguros Monterrey New York Life, S.A. de C.V. I also accept the responsibility to inform the holders.
the personal data provided in this application and the purposes of its processing.

I manifest my consent to receive from Seguros Monterrey NewYork Life, S.A. de C.V., either directly or by
through an authorized third party, the offering of financial products and services through advertisements,
promotion and/or telemarketing through any of the contact methods provided in this or any other format.
Insured Yes No Beneficiary Yes No
Note:Incaseofnon-acceptance,theprocessingofyourdatawillbelimitedtotheprimarypurposesandtransfersthatdonotrequire
consentindicatedinthePrivacyNoticeofSegurosMonterreyNewYorkLife,S.A.deC.V.,inthecaseof
selecttheoptionnottoreceiveadvertising,promotions,andtelemarketing,SegurosMonterreyNewYorkLife,S.A.deC.V.willretain
theregistrationintheirinternalrecordstonotsendadvertising,promotion,andtelemarketingfortwoyears,onceelapsed
thedeadlinewillproceedtocancelsaidregistration.Torenewitoncethedeadlinehaspassed,youmustrequestitthroughthe
mechanismindicatedinthePrivacyNoticeofSegurosMonterreyNewYorkLife,S.A.deC.V.
The undersigned requests and authorizes any hospital, doctor, or person who has attended to or examined me to
any reason, to provide Seguros Monterrey New York Life, S.A. de C.V. or its representatives, all the
information related to diseases, injuries or ailments that you have suffered, such as medical history,
consultations, prescriptions, treatments, clinical studies (radiographs, laboratories, etc.), copies of clinical records
formed in hospitals or prepared by the doctor. This information may be included as part of the evidence of the
compensation submitted by me to the Company. The photocopy of this authorization must be considered as such
effective as the original.

Name and signature of Insured Name and signature of payment beneficiary Name and signature of legal representative

In compliance with the provisions of Article 202 of the Law on Insurance Institutions and
Bonds, the contractual documentation and the technical note that make up this insurance product,
they were registered with the National Commission of Insurance and Bonds, starting from the 20th of
December 2019, with the number CGEN-S0038-0121-2019.