LTO Form No.

28

Republic of the Philippine*';,i-ril*x;;r;€'r:4'-i:,1;:'

V
DEPARTM ENT OF TRANSPORTATION
LAN D TRANSPORTATION OFFICE
East Avenue' Quezon CitY

p1s16 91116s.i ;* =in=!

l':l:-lriri iiiiiF Field Office 666g j:Ie

862405031- DArE:

RECEIVED FROM (Last name, Fist name' Ml)

EI{ SE*I''G Y*}JG
ADDRESS INo.. Street, Citv Municipatity. Provingg ZJP-Q"d1!---.-:-
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6th Fioor Zeia IL{nnex Builciing. 191 Salcedo Srs:r. Leg...r: \'illage 1229 Makati City
Trunk Lines: 159-2920. i59-2921 . 759-i082 . SSU-:;qt . S9l-002i . 893_0026
Fax No. 892-3794 . 759-2886 TtN # 001 -009-467

NAME AND ADDRESS OF INSURED

STAND.ALONE
PRIVATE CAR POLICY

C - l'{9 TrzrSg

BUSITIESS/PROFESIOilI jcor,rnnr,rnnolr oFCOVERNo.

tl
!'oak " ecc.i'- JooS
$mlta -.etrl,Le
.

.I I- " PERTODOF

SCHEDULED VEHICLE

S:: -: - aTjASSIS NO. Al-Tr-3RllEl :: r::- -'

::'- ' :u-, t r, t ,\rv 1c0,c00 a,
THIRD PARTY LIABILITY
(Subiect to the Schedule of Indemnities)

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TOTALAMOUNT DUE P

AUTHORIZED DRIVER:

Any of the following: (a)

The Insured
(b)
Any person driving on the I n s i..: red's order or with h is permission.
Provided that the person driving is permitted. in accorda;rce with the licensing law or other regulations,
to drive the Scheduled
Vehicle, or has been oermitted and is notdisoua':tred byorderof a Cou{cf LarvLrby reason
of anyenactmentorregulation inthat
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Et iite iinie of ine accioent nac exptiec.

LIMITATIONS AS TO USE:

Use only for social, domestic and pleasure purposesr and for the insured's business or profession. The policy
does not cover
( 1)
Use for the hauling and/or ca rrying of logs, iumber, sand, gravel, bottled beverages, gasoline prod
ucts a nd/or other
inflammable articles or materials.
(2)
Use for racing, pacemaking, reiiability trial or speed testing.
N'8. Provided that limitations (1) and (2) above may be deleted and the risks named therein covered by this policy
upon agreement
by, and payment of 20olo additional premium to the Company.
(3)
Use for the carriage of pASSENGERS or for hire or reward.
(4)
Use for any purpose in connection with the Motor Trade.

SECTIONS I and II of this Policy cover THIRD PARTY liability arising from bodily injury and/or death in amounts set forth under the
Schedule of Indemnities.

IN UIITNESS IVHEREOF, the Compa*y has caused this Poliry to be signed by its duly authorized officer/representative
-t
oi Philippines, this _ day of ?n

Doc&Eentary Stamps to tfie \ralne sEEd

above bave been atnxed and properly
cancelled on the office copy ofthis p.lic1

W
IMPORTANT XSTIC€ STERLTNG TNSURANCE COMPANY, rNC.
The Insurance Commbrioner, with ofEes in !,ldlila, Cebu and Dayao is llle
Govemment officiil in chargeof ftefaithfutqantim atd enforemet*of all lass
r€lating to insurane and has supen ision oyer irErr?ne campanies, He is ready at
all tims to rcnds asistare in s€,ltlini, aay &r*rotqsy b€t\@n an insare
 @F

WHEREAS THE INSURED, by his corresponding proposal and declamtion, and which shall be the basis of this Contract and deemed incorpomted
herein, has applied to the company for the insumnce hereinafter contained, subject to the payment of the Premium as consideration for such
insumnce.
NOW THiS POUCY WTTNESSETH:
That, in respect of events occurring during the period of Insurance, and subject to ilre terms, exceptions and conditions contained herein
or endorsed hereon (hereinafter collectively refened to as the Terms of this Policy):

SECTION I . LIABILIW TO THE PUBLIC

1. The Company will pay all sums necessary to discharge liability of the Insured, arising from all expenses and damages
directly resulting from any bodily injury and/or death to any Third Party (excluding all moral, exemplary and other
incidental damages, expenses and loss of income) in an accident caused by the use of the Scheduled Vehicle, provided
that the insured's liability shall have first been determined, but not exceeding in the aggregate P 100,000 per occurrence
or any one occurrence regardless of the number of individual claims^
2. In terms of and subject to the limitations of this Policy, the Company will indemnify ;
Any authoi'ized Driver who is driving the Scheduled Vehicle, provided that he:
(i) Observes, fulfills, and be subject to the Terrns of this Policy insofar- as they can apply;
(ii) isnotentitlecltoindemnityunderanyotherpolicysubject,hcwever,toConditiorNc.SoftheConditionsApplicable
To All Sections;
3. Intheeventof the deathofanypersonentitledtoindemnityunderthisPolicytheComcanyT"ill, inrespectoftheliability
incurred to such person indemnify his personal representatives in terms of, and sullecl to the terms and conditions
hereof,
4. In the event of accident involving indemnity underthis Policy to more than one eeison, the Limits of Liability shall not
exceed the aggregate amount so specified by Law to all persons to be indemniiec, Shou ld indemnification both to Iiability
of the lnsured and thatof another party ( as prcvided underAuthorlzed Driver I re provable, the rnsur-eC's shaii '- ' ..' )"
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5. Uitess the Insured objects, the Compa ny sha ll:-

{a) arrangeforrepresentationatanvinquestorinvestigationinrespectofanydeathwhichmaybethesubjectof
indemnity under this Section;
(b) Undertake the defense in the Insurance Commission under Section 385 of the Insurance Code, or in any court of law,
for aileged offenses causing, or relating to, any event which may be the subject io indemnity under this Section.

SCHEDULE OF INDEMNITIES FCIR EODILY IN]URY AND/OR DEATH

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fees and hospital charges for services rendered to, traffic accident victims under the Compulsory Motor Vehicle Liability lnsurance
coverage.
A. DEATH INDEMNITY Ps 7O,OOO.OO C, PER.,IANENT DISABLEMENT AMOUNT
Burial and Funeral Exoenses 30,000.00 r-css of or Loss of Use of
B. BCDiLY iN]URIES AND FRACTURES l'laximum
T": 'inrbS Ps 50,000.00
Types cf AccornmoCation or allfingers & both thumbs 50,000.00
Piofessiona; Attenda nce Reimbursabte Fees 33[il F#t'or 50,000.00
Extended Services Rendered andlor Charges One Hand & One foot 50,000.00
Sight of Both Eyes 50,000.00
L. Hospital Rooms Maximum of 45 days per accident Ps 500.001day Injuries resulting in being permanentlv
Laboraiory Exanination Fees
X-rari s 2,C00.00
bedridcen 50,000.00
Any other in;u:r c:-s:rc ce"rarert
total disablement 50,000.00
2. Surgical Expenses lvlajoi' Operation 7,500.00
Arm at or abor.,e e 3oi', 20,000'00
5,000.00
Medlunt Operation
Arm between eiboi'i ard',vrist 15,000.00
1,500.00
Minor Operation
2,500.08
Hand 15,000.00
Four fingers and ih;nl of one hand
3. Anaesthesioiogist's Fees l'1ajor Operation 15,000.00
2,000.08
Four Fingers
Medium Operation 12,000.00
s00.00
Leg at or above knee
Minor Operation 20,000'00
4. Operating Room Major Operation 1,500.00
Leg below knee 15,000.00
1,000.m
One foot
Medium Operation 15,000.00
s00.ffi
All toes of one foo:
Minor Operation 10,000'00
5, Medical Expenses For daily visits sf Practitioner oi'
Thumb 8,000.00
400.00/day
Inclex Finger
Specialists 6,000.00
The loial amount of medical
Sight of ohe Eye 20'000.00
Hearing-both Ears
Expenses must not exceed 30,000'00
(For a single period of confinement) 5,000.00
Hearing-one Ear 15,000.00
6. Drugs And Medicine Actual value of drugs and
Medicine used but not to 20,000.00 D. exceed OTHER INCiDENTAL EXPENSES
7. Ambulance Actual amount charged for arnbulance The Company will pay all pertinent and reasonable
Transport but not io exceed 1,500.00 expenses incurred in connection with the accident not
provided under this Schedule of Indemnities (A), (B)
and (C) subject to a maximum amount of P
10,000.00 but in no case shall the companyt
aggregate payment exceed the overall Limits of
Liabilily under Sections I and II.
 SECTION II - NO FAULT INDEMNIW
]iillilff:J#:ff,n,;:'r:fl[.t!ffi Iv injurv and/or death to anv rHrRD pARry
w*hou*he necessity or provins raurr
(a) the total indemnity in respect ofany
one THIRD PARW shall not exceed Fifteen
schedule of Indemnities in case oi Juuil'l Thousand pesos, subject to the foregoing
or. prrvri.ur'i";rrv, iritr,"ut prejudice
t" tn" craimant from pursuing his craim
Ili::*il,,H',?,;ffiilxJ$U:,i;nx;",.:;iffi:1,:01, the companv io u,-".,t" any
Quit iiaim or document
(b) the following proofs of loss, when submltted
u nder oath, sha ll be sufficient
( i) Pol ice report of evidence to su bsta ntia te the cla im; -
accioeni or any evioence surncient to
(ii) Medicar report and evidence estlbt ;ih trre accident, a nd
oi meJaat or trospitai expenses and or
(iii) Death certificate and evidence l ;
suinii"nt to esta biish the proper payee.

GENERAL EXCEPTIONS
The Company shaii nct be iiabie under
anv section of this poricy in i-espe:i
cf;_
1.

2.

J.

anc
4.
been entitled to recover rrom any party
but for an agreement between thE
any person in the employ of the Insured
arising out of and in tJre course of such
andlor death to any member or tne tnsurlc!
housenotd who is riding in the Scheduled

DEFINITIONS
1
Y:Iti Y:'-t:= -',:i'J=." ' I :: :--.t'"t: -' t"^.t]oi ]ny, paras raph (a ) or Repubric A* --rlurnbe.ed Four rhousand one
2' t^ith;i-;, ;;. j;;";;"."*;;
rHiRD PARrY unv o"ion o,n".,nuj,
or a member of'' the family within the
i"or"ol. ,n;l*;r"" .;. i.1*
respect of death, bodily injury or da
s:cond degree "'. uehicre owner or his emproyee
or affinitv, or, ,oio,.
r-r age to pro[erty "i."rl""grinity
arislng ou't orano in the course of employment. in

CONDITIONS APPLICABLE TO ALL SECTION

1' This Policy and the Schedule shail
be r':ac icEether, as one contract, and
has been attached in any part of any word or expression to which a specific
this Pc'r:',' ci' of the Schedule shall bear meaning
2' Every notice or communication to be g
ive r o;- made under this poticy shall
such specinc melnlng i,rrherever it may appear.
be d;liv;r; ;;riting to the Company.
3' The Insured shall mainta in the sched-u
lec Veh icle in efficient conditicn, a nd
the Compa ny sha I have at a, times free
access to examine the Scheduled and fu Ir
Vehicie or a ny part thereof or any driver
4' Intheeventofanyaccidentwhich or employee of the Insured.
maygiverisetoaclaimunderthisporicy,trrelnsureashalr.assoonaspossibre,give
notice thereof to the company wiih full particulars.
Every leiter, claim, writ, summons and process
forwarded to the Company immediately shall be notified or
on r-eceipt. Notice shali also be given
Insured shall have Knowledge ol any impending to the company immediateiy as soon
as the
ci-osecution, inquest or fatal inquiry in connection
Incaseofcarnapping with any such occurence..
orotherci-iminalactwhichmaygiverisetoaclaimunderthispolicy,thelnsuredshallgiveimmediate
notice to the Police and cooperate with "securing
ihe Compa ny in
5' without preiudice to No' 2 of the General ttre conviclion of the offender,
Exceptlons, no uJrir'riln, offer, promise
of the Insured without the written consent or payment shaii be made by or on beharf
of the Company whicn shalr be entifled
defense or settlement of any ciaim, or to take over the conduct in his name the
to prosecute in his name for its own nan"nr
otherwise' but shall not exercises any discretion unv .laim for indemnity or damages
prejudicial to the interest of the lnsured or
in the conduct of any proceedings
il:iHffiTilfl,1tr,?:kllifli,l::::fftr[*i];;*lis:****itr:]::L:::r!.mqanvmavrequ re rr
 I

6. Atanytimeafterthehappeningofanyeventgivingrisetoa::: inorseriesofclaimsunderthisPolicy,theCompanymaypay
to the Insured and the Third Party claimant jointly the ful .rc;nt of the Company's liability and relinquish the conduct of
any defense, settlement or proceedings, and the Company s.a not be responsible for any damage alleged to have been
caused to the Insured in consequence of any alleged action cr :n ssion of the Company in connection with such defense,
settlement or proceedings or of the Company relinquishing s-rc" ccnduct, nor shall the Company be liable for any costs or
expenses whatsoever incurred by the Insured or any cla ima nt or cirer person after the Company shall have so relinquished,
Tre Company may cancel this Policy in accordance v,,ith Sections 54,65, and 380 of the Insurance Code, in which case, the
Company shall thereupon reiurn ic the Insrred lreni,;ms paic ess the pro rata cortioir thereof for the period when the
Policyhasbeeninforce. Thelnsuredmay,atanytime,canceirnePolicybysurrence'irc t:oineCompanyand(providedno
claimhasarisenduringthethencurrentperiodoflnsurance) thelnsuredshali:=e:t;tledtoareturnofthepremiumatthe
Company'sShortPeriodRatesfortheperiodwhenthepolicyhasbeeninforce. -3ivever,inrespectofSectionlandll,the
-
cancellation made by the lnsured shaIl not be effective unless he has secured a s rar policy of insurance or surety bond to
replace the policy to be cancelled or make a cash deposit in sufficient amount r, :- Ine Commissioner and without any gap
file within five (5) working days from the date of cancellation the requirec jocumentation with the Bureau of Land
Transportation in accordance with Section 381 of the Insurance Code.
B. If,atthetimeanyclaimarisesunderthisPolicy,thereisanyotherinsurarce
:i.v'eringthesameloss,damage,orliability,
theCompanyshallnotbeliabletopayorcontributemorethanitsratabre:'c:crtionof anyloss,damage,compensation,
costs or expenses. Provided always that nothing in this Condition sha '* I rse on the Company any liability from which,
but for this Condition it would have been relieved under proviso (ii) of Se:: or. i -2(a) of this Policy.
9. In case of any dispute in the enforcement ofthe provisions of Src:,on I and Ii of this Policy, the adjudication of
suchdisputeshallbewithintheoriginalandexclusive jurisdictic'cf thelnsuranceCommissionersubjecttothe
limitations provided in Section 416 ofthe Insurance Code, as amerded.
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10. =--=--:: =.' :-'-t
to be done by the Insured, and the truth of the statements and answer in the proposal, shall be conditions
precedent to a ny liability of the com pa ny to ma ke any payment under th is po licy,
11. In the event that the Company should pay or be held liable to pay any claim or claims under the "No Fatrlt"
provision ofthe Insurance Code, the Insured shall reimburse the Company al I such sums, wheneverthe Insured
orhisauthorizeddriverorrepresentativehascommittedabreachofanyofthewarrantles,clausesorconditions
of the Policy, or whenever the circu msta nces fa ll u nder a ny of the EXCEPTiONS listed in the Policy, for wh ich the
Com pa ny wou ld not have been lia ble were it not for the a pplication of the " NO- FAU LT" provision of the I nsu ra nce
Code,
NUCLEAR EXCLUSIONS CLAUSE

1. This Policy does not cover: *---

a) Lossordestructionof,ordamagetoanypropertywhatsoeveroran','cssorexpensewhatsoeverresultingorarising
therefrom, or any consequential ioss;
b) AnylegalliabiliQof lq/hatsoevei-nature,directiyorindirectl,vcausecby,orcontributedtoby,orarisingfrom,ionizing
radiationsorcontamtnaticnbyraoicaciivityfromanynucleaifue,orfromanynuclearwastefromthecombustionof
nuciearfuel.Forthepurposeof thisexciusiononlycombustionshallincludeanyself-sustainingprocessof nuclear
fission.
2' The indemnity provided by thls Policy shall not apply to nor include any loss, destruction, damage or legal liabillty directly or
indirectly caused by or contributed to, by, or a rising from, n uclear weapons materia i.

CIWL CODE ARTICLE 1250 WAIVER CI.AUSE

ITiSHEREBYDECLAREDANDAGREEDthaithe provisionsofAnicle 1250 of the Civil Ccce oi the Philippines (RepublicAct No.
386) which reads:
--
"In case an extraordinary inflation or deflation of the currenry stipulated should supervene, -ce value of the currenry at
the time of
the establishment of the obligation shall be the basis cf pavment,.," shall not apply in. determ:i-l,ng the extent of liability under the
provisions of this Policy,

SHORT PERIOD RATE SCALE

It is hereby agreed, in the event this Policy is surrendered by the insured for cancellation, the Company shall retaln a premlum in
accordance wiih the following scale for the time the policy has been ln force: ---

No. of Month/s 1 2 3 4 5 6 7 B 9 10 11
20 30 40 50 60 /u 75 BO B5 90 95