CONFIRMATION OF COVER

PGA Sompo Insurance Corporation No. 00123

A joint venture between: Prudential Guarantee and Assurance Inc. and Sompo Japan Nipponkoa Insurance Inc.
________________________________________________________________________________________________________________

This confirms that the person named below is insured under and subject to all terms, conditions, warranties and
clauses of the above stated policy.

Issue Date: February 01, 2020

Insured Name: LASCUÑA, JOHN BENEDICT
Insured Address: 117 camia st., san jose village 2, phase 5, biñan, laguna
Beneficiary: Succession of Law Premium: 523.48
Relationship: Doc Stamps: 200.00
Contact No.: 09178725586 Premium Tax: 10.47
Travel Date: February 02, 2020 to February 08, 2020 LGT: 1.05
Destination South Korea Total: 735.00
Amount of Insurance: Php 1,000,000.00
BENEFITS Limits of Liability
Medical Expenses (Cashless for In-Patient Cases) UP TO 1,000,000
Evacuation & Repatriation Actual Cost
Personal Injury / Accident 1,000,000
Personal Liability UP TO 1,000,000
Trip Cancellation or Trip Curtailment 70,000
Rescuer's Expense Indemnity (Including Compassionate Visit) UP TO 500,000
Baggage Delay 5,000
Baggage and Personal Effects Liability UP TO 50,000
Flight Delay UP TO 50,000
Loss of Personal Money Extension MAX 15,000
Loss of Travel Documents MAX 5,000
Strikes / Hijacking 1,000/day max of 10 days

DOCUMENTARY STAMPS CLAUSE (DST)

Under Pertinent regulations of the Bureau of Internal Revenue, liability for documentary stamp
tax (DST) accrues upon issuance of the insurance policy. Hence, in the event of policy cancellation,
liability for the DST subsists and the same shall be chargeable to the Assured.
Under Pertinent regulations of the Bureau of Internal Revenue, liability for documentary stamp
tax (DST) accrues upon issuance of the insurance policy. Hence, in the event of policy cancellation,
liability for the DST subsists and the same shall be chargeable to the Assured.

IMPORTANT NOTICE: The Insurance Commissioner, with offices in Manila, Cebu and Davao is the government official in
charge of the faithful execution and enforcement of all laws relating to insurance and has supervision over insurance
companies. He is ready at all times to render assistance in settling any controversy between an insurance company and a
policyholder relating to insurance matters.

NOW THIS POLICY WITNESSETH that in consideration of the payment of the premium as stated herein, the Company
agrees subject to the terms, exceptions and conditions provided in the Group Policy during the period specified herein to pay
to the Insured's or to the Insureds or Executors or Administrators, according to the schedule of Compensation up to the extent
and in the manner therein provided against loss resulting directly and independently from Bodily Injury caused by sudden and
accidental happening occurring in the course of the travel which includes loss of life, physical impediment and medical
expenses indemnity.
LIMITS OF LIABILITY
The liability of the Company shall be limited to the amount stated in the Confirmation of Cover and shall not exceed amounts
stated therein in the annual aggregate.
5th Floor, Corinthian Plaza, 121 Paseo de Roxas, Legaspi Village, Makati City, Philippines
Phone: (632) 8811 3417 Fax: (632) 8811 3278 / 8892 3922

Form No. 009.12.2014

 GENERAL EXCLUSIONS
The Company in no case shall be liable for bodily injury caused by any of the following cases:
1. Willful act of the policyholder (if policy holder is a corporation, the policyholder hereunder means any of its directors or any
organ of the corporation to execute its corporate duties) or the insured
2. Willful act of a person who is entitled to indemnity (if a corporation is entitled to indemnity, the person so entitled hereunder
means any of its directors or any organ of the corporation to execute its corporate duties) but in case such person is entitled
to a part of the loss of life indemnity, this exclusion does not apply to the amount which any other person is entitled to
3. Suicide or attempt thereat or criminal act of the insured, or act of aggressive violence initiated by the insured
4. Accident occurring while the insured is driving an automobile or a motor-bicycle without having qualification to drive it in
accordance with the stature of the place where the insured drives or under the influence of alcohol, narcotic, hemp, opium,
stimulant, thinner or the like, to the extent the insured may be incapable of controlling the vehicle
5. Sickness, AIDS, dental disease, brain disease or insanity of the insured
6. Pregnancy, childbirth, premature birth or miscarriage of the insured or medical or surgical treatment of the insured (except
such as may be necessary solely by injuries against which the company will be liable to pay indemnity)
7. Execution of a sentence on the insured
8. War, military act of foreign nations, revolution, insurrection, civil war, armed rebellion or other similar disturbance or riot (for
the purpose of this exclusion "riot" means the state of affairs in which national or local good order is seriously disturbed by
collective action of a group or groups of persons, and in which a serious threat to peace and order is deemed to exist)
9. Radioactive, explosive or other hazardous nature of nuclear fuel materials (hereinafter including spent fuel) or properties
contaminated by nuclear fuel materials (including products yielded in the process of nuclear fission) or any accident arising
from such nature
10. Any accident incidental to exclusions stated in the preceding two subsections, or any accident arising out of the
disturbance of good order incidental thereto; or
11. Nuclear radiation or radioactive contamination not included in section (9) above
12. The company in no case shall be liable for cervical syndrome (so called "whiplash syndrome") or back pain, from any
cause, without objective symptom
OTHER CONDITIONS
1. Compensation shall not be payable under more than one of the items of the Schedule of Compensation provided for in the
Group Policy Schedule in respect of the consequences of the same accident.
2. The total sum payable under this Policy in respect of any or more claims shall not exceed in all the largest sum insured
under any one of the items contained in the Schedule of Compensation plus Medical Expenses as provided in the Group
Policy Schedule.
NOTICE OF ACCIDENT AND FILING OF CLAIM
1. When the insured shall sustain a bodily injury as stated above, the Group Policyholder, insured or any person who is
entitled to indemnity (including their representative) shall give notice thereof, containing information regarding circumstances
of the accident and the extent of the injury, to the Company within 30 days commencing from the date of accident causing
such injury. The Policyholder, the insured or any person entitled to indemnity shall comply with the Company's request for
notice in writing or explanation or medical or postmortem examination of the insured.
2. When the aircraft or watercraft in which the insured was riding has disappeared or met a disaster, the Group Policyholder
or the insured (including his or her representative) shall give written notice thereof, covering the circumstances of the
disappearance or disaster, to the Company within 30 days commencing from the date of the disappearance or disaster
3. The Company shall not be liable under this insurance in the event the Policyholder, the insured or any person entitled to
indemnity, without reasons satisfactory to the Company, fails to comply with the requirements as stated in the preceding
paragraphs above or fails to represent any known fact or makes a false statement in the notice or explanation thereof
FILING OF CLAIM
1. In case of claim including request for payment of medical expenses indemnity to an organization tied-in with the Company
pursuant to the provision of Paragraph 4 Article 7 of the Group Policy Schedule (Payment of Medical Expenses Indemnity),
the insured or the person entitled to indemnity (including his or her representative) shall furnish to the Company such
documents as required by the Company among those list in Table 4
2. The Company may request submission of any other documents in addition to those listed in Table 4
3. The Company shall not be liable under this insurance in the event the insured or the person entitled to indemnity fails to
submit the documents as stated in the preceding two paragraphs or fails to represent any know fact or makes a false
statement in the documents furnished to the Company.
CONTACT NUMBER FOR MEDICAL TREATMENT: CONTACT IN CASE OF CLAIM IN THE PHILIPPINES
GO WORLDWIDE Mr. Reynaldo M. Marcelo
Hotline Number (+632) 459-4733 Claims Manager - PGA Sompo Insurance Corp.
DID (02) 7055560
tpa.claims@pgasompo.com