NON-LAND TRANSPORTATION OPERATOR'S VEHICLE Client's Copy

CONFIRMATION OF COVER NO. 0915207493

AUTHENTICATION NO.: 091JNDWQ2209 POLICY NO.
SI-PCV-500628115
NAME AND ADDRESS OF INSURED BUSINESS DATE ISSUED
ROLANDO ZABALA CLAVERIA New Business 05/23/2022
AGENT'S CODE 10000109 PAID UNDER O.R. NO.
59 IPIL ST. VERDANA HOMES PERIOD OF INSURANCE
MAMPLASAN - BIÑAN, LAGUNA
Laguna FROM 05/19/2022 TO 07/01/2023
SCHEDULED VEHICLE
MAKE/MODEL/BODY TYPE SERIAL/CHASSIS NO.
2019 FORD RANGER 2.0L RAPTOR PICK-UP MPBUMFE60KX242720
PLATE NO. COLOR MOTOR NO. MV FILE NO.
DAN6236 ABSOLUTE BLACK YN2QX242720 0401-00001043770
SECTION I/II THIRD PARTY LIABILITY LIMIT OF LIABILITY 100,000 PER ACCIDENT
(Subject to the Schedule Of Indemnities shown in the Master Policy) PREMIUMS
This Confirmation of Cover is evidence of the policy of insurance required under
insurance required under chapter VI - Compulsory Motor Vehicle Liability Insurance PREMIUM 501.99
RMA 230 of the Insurance Code amended by Presidential Decree No. 1814 PREMIUM TAX 60.24
DST 62.75
LGT 1.00
TOTAL 625.98
RMA 230
John B. Echauz Divinia D. Mitra AUTHENTICATION FEE 50.40
Rev. 3-1 President and CEO Head -Risk Management Division
06/22/2015
TOTAL AMOUNT DUE 676.38

NON-LAND TRANSPORTATION OPERATOR'S VEHICLE LTO Copy

CONFIRMATION OF COVER NO. 0915207493

AUTHENTICATION NO.: 091JNDWQ2209 POLICY NO.
SI-PCV-500628115
NAME AND ADDRESS OF INSURED BUSINESS DATE ISSUED
ROLANDO ZABALA CLAVERIA New Business 05/23/2022
AGENT'S CODE 10000109 PAID UNDER O.R. NO.
59 IPIL ST. VERDANA HOMES PERIOD OF INSURANCE
MAMPLASAN - BIÑAN, LAGUNA
Laguna FROM 05/19/2022 TO 07/01/2023
SCHEDULED VEHICLE
MAKE/MODEL/BODY TYPE SERIAL/CHASSIS NO.
2019 FORD RANGER 2.0L RAPTOR PICK-UP MPBUMFE60KX242720
PLATE NO. COLOR MOTOR NO. MV FILE NO.
DAN6236 ABSOLUTE BLACK YN2QX242720 0401-00001043770
SECTION I/II THIRD PARTY LIABILITY LIMIT OF LIABILITY 100,000 PER ACCIDENT
(Subject to the Schedule Of Indemnities shown in the Master Policy) PREMIUMS
This Confirmation of Cover is evidence of the policy of insurance required under
insurance required under chapter VI - Compulsory Motor Vehicle Liability Insurance PREMIUM 501.99
of the Insurance Code amended by Presidential Decree No. 1814 PREMIUM TAX 60.24
DST 62.75
LGT 1.00
TOTAL 625.98
RMA 230
John B. Echauz Divinia D. Mitra AUTHENTICATION FEE 50.40
Rev. 3-1
President and CEO Head -Risk Management Division
06/22/2015
TOTAL AMOUNT DUE 676.38
 SCHEDULE OF INDEMNITIES FOR BODILY INJURY AND/OR DEATH
The following Schedule of Indemnies shall be observed in the se9lement of claims for death, bodily injuries and professional fees and
hospital charges for serviced rendered to traffic accident vicms under the Compulsory Motor Vehicle Liability Insurance Coverage.
P 70,000.00
A. DEATH INDEMNITY C. PERMANENT DISABLEMENT AMOUNT
Burial and Funeral Expenses 30,000.00 Loss of or Loss of Use of:
B. BODILY INJURIES AND FRACTURES Two Limbs P 50,000.00
Types of Accommoda on or Maximum Both hands, or all fingers
Professional A'endance Reimbursable Fee & both thumbs 50,000.00
Extended Services Rendered and/or Charges Both Feet 50,000.00
One hand & one Foot 50,000.00
P 500.00/day Sight of both eyes 50,000.00
1. Hospital Rooms Maximum of 45 days per accident
Injuries resulng in being 50,000.00
Laboratory Examinaon fees, X-rays 2,000.00
permanently bedridden
2. Surgical Expenses Major Operaons 7,500.00 Any other injury causing 50,000.00
Medium Operaon 5,000.00 Permanent total disablement
Minor Operaon 1,500.00 Arm at or above elbow 20,000.00
Arm between elbow and wrist 15,000.00
3. Anaesthesiologist’s Fee Major Operaons 2,500.00 Hand 15,000.00
Medium Operaon 2,000.00 Four fingers and thumb of one hand 15,000.00
Minor Operaon 500.00 Four fingers 12,000.00
Leg at or above knee 20,000.00
4. Operang Room Major Operaons 1,500.00 Leg below knee 15,000.00
Medium Operaon 1,000.00 One foot 15,000.00
Minor Operaon 500.00 All toes one foot 10,000.00
Thumb 8,000.00
5. Medical Expenses For daily visits of 1,500.00 Index Finger 6,000.00
Praconer or Specialists 1,000.00 Sight of one eye 20,000.00
500.00 Hearing - both Ear 30,000.00
The total amount Hearing - one Ear 15,000.00
of medical expenses must not exceed 5,000.00
(For a single period of confinement) D. OTHER INCIDENTAL EXPENSES
The company will pay all pernent and reasonable
6. Drugs and Medicine Actual value of drugs and medicine expenses incurred in connecon with the accident not
used but not to exceed 20,000.00 provided under this Schedule of Indemnies (A), (B), and
(C), subject to a maximum amount of P10,000.00 but in
7. Ambulance Actual amount charged for ambulance no case shall the company’s aggregate payment exceed
transport but not to exceed 1,500.00 the overall Limits of Liability under Secons I and II.