913A121.

10:27 All Liberty,nsurance Corporatign

Jose Cojuangco Sons Building

I l9 Dela Roaa cor C. palalca Str*ts, Legmpi Viliage"

LIBERTY INSURANCE Makati City Philippioas

Tel- No- 8-8i9-i961 1o 66
Fax. No. 8-819-5217 I 8-8i8-8639
Emdl: info@libe*yinsuane.com.ph
CORPORATION Websit€: b,tta J,{ ibertyiffiwance.com.ph/

Date: SepLembcr 30. 2(i"?.1

TRAVEI- IN S TTr{ANCE C ON FIRJ?IATTON OF CO \'-ER,{GE NO. T PAOO6S43 TIOO 1

Name Birthdav BeneliciarY

ME|.I[}L)ZA. X4ARILOU QUICIiO 02ilflriir7,\

lfinerary: \{anil* - Sarcli Arabra - f)antiuirrt

Dura{iau:' iiom October l. lt}2 1 to Oclr-rber L5, 2{}: I for i 5 d.t1's.

A ui lroriz+d Si gn *tor,v -\gent's Conitrti \rrnrher {i9 1 ?til38.t?7

JOSEFINA M, SALYADOT{
Pms:ideht ed Chief OperBtingOlEcer
ALIT] ,ORIZF-D SIGN,g.T1]RE

C()C Issued By Samarituu Resources (RLllO Date Issutd Sepleml).r 3{!, 2$? I

3 Col" Marcelino St. Cor. Gen. Lim

Heroes Hills, Barangay Sta. Cruz
Quezon City

Sales Person tName Signatue) I certi$ that I have validated the inf,ormalion in tbe applicaticr against the
original I.D. card/s ptesented a1ld have established the applicant's identity.
Reynaldo Cipriano

of al1 the laws

IMP0RTANT NOTICE: The Insmnce Comission with offices in Manilq Cebu and Davao is the Govemmt Office ia chrge of the faithful executioil and enforcement

Policyholder relating to innrance matt66.

In case of emergency. immediately get in touch with ASSIST AMERICA Tel. No.: (+632) &811 2521 I Viber: 091?-5622-100

Note: Under Republic Act 9160 (irnti-Money lauderiag Act) as amended by Republic Act 9194 ffid pertinmt regulatios, all insffince companias are required to satisfactorily establish the

his idenfiry.

lYorldrvide
Schedule of &
lollllv 5ti00{-i0.{}0
Assistancc CASg 10.00ti
incotlc I Max. 1

ol the Insured'-* 10,000

lmcre.ercv [Jental Cart 25,tXl{i

Deiiverv of Mc'rlithes tlniimited
t ith the Actual llxpenses
o{'tulortal r\ctual llxpenses
rll trfle idenbcr I Compassioraie Ttavel Costs plus 2,500 per Day Msx.
100,000
Travrl tlosls plus ),500 per Day ivlat.
l0ti"(l0{i
Unlimitctl
i\dvancc oi- I-]ail iii:irii ,!00.00{}
Adlrrrcr: oi Moncv 50.0t)0
).00i)
lrip Carccllation
50.t){r{_}

LLrss oiPasspolt. I)river's 1-iccnse, National I.D Ahraad 1:.500

2.1i0* i;er Dar , l,lax- 20,0C0
i00,000
I2,500
I2,500
Unlimited
Deiry (tliie to i:'lighr Diversior. Failures and

6 be
b) lfbeyond l2 Hours Delayed Ilcpanttre I to
Iles;rrdless if6 to 12 l-[orrrs or 12 llours L)elaved Denarlurc Onlv) "00t)