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 OUTSIDE X LUXURY LTO DATE : 05-Jan-22
ASSURED NAME : TRISTAN BLU GALANG
ADDRESS : #54 SITIO DALIG BAGUMBAYAN PILILIA RIZAL

TELEPHONE NO. : 0998554003 E-MAIL : BIRTHDAY :

PERIOD COVERED : JANUARY 5, 2022 INSURER : PEOPLE'S

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

MAKE & MODEL : 2019 TOYOTA INNOVA J DI M/T MORTGAGEE : N/A

CHASSIS NO. : PA2CA8EM7K0057285 MOTOR NO. : 1GD0598152
PLATE NO. : NBS 3018 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 : 870,000.00 9,570.00
V/EXBI : 200,000.00 420.00
V/TPPD : 200,000.00 1,245.00
PPA : 175,000.00 FREE
CTPL :
AOG : 870,000.00 2,745.00
NET PREMIUM 13,980.00
DOC. STAMPS 1,747.50
VAT 1,677.60
LOCAL GOV'T TAX 104.85
TOTAL AMOUNT DUE
Php 16,000.00
.==========================================================================================================================
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:____________________