TOYOTA TAYTAY RIZAL INC. 15 A. Manila East Road. Brgy.

Dolores, Taytay, Rizal 1920

Insurance Division Tel:(02) 8653-7247/Website:www.toyotataytay.com

APPLICATION FORM
RENEWAL X OUTSIDE LUXURY LTO DATE : 11-Jan-22
ASSURED NAME : TFSPH LEASED TO: ROSINNI ANN BERNARDO MAGBOO
ADDRESS : #54 SITIO DALIG BAGUMBAYAN PILILIA RIZAL

TELEPHONE NO. : 0998554003 E-MAIL : BIRTHDAY :

PERIOD COVERED : JANUARY 5, 2022 INSURER : FROM MALAYAN TO PEOPLE'S

.=============================================================================================================================
VEHICLES DESCRIPTION:

MAKE & MODEL : VIOS 1.3 XLE CVT-EK-026 MORTGAGEE : TFSPH

CHASSIS NO. : PA1B18F32M4133965 MOTOR NO. : 1NRX649150
PLATE NO. : S0M012 COLOR : THERMALYTE
MVFILE :
ACCESSORIES:
BUILT-IN ( Aircon, Mags, Stereo w/ Speakers) X

OTHERS 1._____________________________ Php ____________ 5._______________________ Php____________

2._____________________________ Php ____________ 6._______________________ Php____________
3._____________________________ Php ____________ 7._______________________ Php____________
4._____________________________ Php ____________ 8._______________________ Php____________

COVERAGE SUM INSURED RATE PREMIUM COMMISSION

OD/THEFT : 756,900.00 11,353.50
V/EXBI : 200,000.00 420.00
V/TPPD : 200,000.00 1,245.00
PPA : 175,000.00 FREE
CTPL :
AOG : 756,900.00 3,784.50
NET PREMIUM 16,803.00
DOC. STAMPS 2,100.38
VAT 2,016.36
LOCAL GOV'T TAX 126.02
TOTAL AMOUNT DUE
Php 19,000.00
.==========================================================================================================================
X
POLICY NO. :____________________________________ FULL DEFERRED SOA
TOTAL PREMIUM :____________________________________ 2 MONTHS CASH
LESS COLLECTION : OR#________________________________ Php____________________ RECEIVABLE:___________________

POSTDATED CHECK : NO. OF PCS. ________________________ NO. DATE OF CHECK CHECK NO. AMOUNT OF CHECK
PR # :____________ BANK/BRANCH:______________________

ISE COMMISION :____________________

LESS DISCOUNT :____________________
NET ISE COMMISION :____________________

NAME OF ISE LEI BARROZO CHECKED BY: _______________________

DATE:___________________ RECEIVED BY:_____________________

TIME:____________________ APPROVED BY:____________________