FRONTLINE SERVICES DIVISION

SPECIAL BUSINESS UNIT

MOTOR VEHICLE
[Manual Bill No.: MGOMAHINOG-06-21-01
NAME OF ASSURED: MGO MAHINOG, CAMIGUIN
ADDRESS: MAHINOG, CAMIGUIN 9101 DATE: June 21, 2021

WARRANTIES AMOUNT OF PREMIUM

PARTICULARS
& CLAUSES INSURANCE RATE AMOUNT
1. STDMV
TYPE OF VEHICLE: MC (MOTORCYCLE)
2. LOSSNOTIC1
3. MV MAKE HONDA
4. MVAE01 TYPE CFT125MRCA MOTORCYCLE 2011
5. AON
6. PSE MOTOR NO. XRM17E020023
7. GSISDST1 SERIAL NO. XRM17020016
8. RDPC/CV/MC
9. UPPA20K PLATE NO. SF-4647
10. UD20K COLOR RED/BLACK
11. ROADASSIST
12. CLAIMSDOC CTPL-BI…………………….. 100,000.00 199.60
Comprehensive Insurance: Business
Type: TG
Loss/Damage (LD)...………. 50,000.00 300.00
Additional Notes: TPL-Excess BI (EBI)……………. 250,000.00 100.00
TPL-Property Damage (PD) 250,000.00 530.00
Deductible [0.01 of LD/AON/S&T] 500.00 UPPA ……………………….. 20,000.00 50.40
Repair Limit [0.01 of LD/AoN/S&T] 500.00 Unnamed Driver (UD)…..….. 20,000.00 50.40
Towing 1,000.00 Acts of Nature (AON)……… 50,000.00 550.00
Other Peril 0.00 -
TOTAL COMPREHENSIVE 590,000.00 1,580.80
expiring policy:
PERIOD COVERED
From August 1, 2021 690,000.00 1,780.40
8100521466 To: August 1, 2022 ADD: Interconnectivity Fee (UB 14-13) 0.00
MORTAGED WITH: DST on Premiums 223.00
MV FILE #
102400000019726 NONE DST on Cert. of Cover (COC) 30.00
For Assureds (i.e. payor) who are withholding Agents (e.g. Government Agency): 12% VALUE ADDED TAX:
If payor opted to withhold 5% VAT, this amount shall be reflected in their CCTWS: (5%) 89.02 [per RR 13-2018 eff 1/1/2021]
If payor opted to withhold 5% VAT, the premiums plus the 7% VAT shall be paid to GSIS: (7%) 124.63 213.65
amount of payment to prepare if paying the premium due plus 12% VAT (and DST, if any) --> 2,247.05
amount of payment to prepare if paying the premium due w/ 7% VAT only, and agency withholds* 5% VAT (and DST, if any) --> 2,158.03
NOTES: Policy shall be issued upon payment of premium.
For comprehensive cover, flat rate for Acts of Nature (Earthquake, Typhoon, Flood, and other natural calamities) is applied.
Premium rate is based on Underwriting Bulletin Nos. 14-06, 16-01, 16-07, 17-01.
Documentary Stamp Tax (DST) effective 7/1/2017 (TG and ONLI); DST discontinued effective 4/3/2018 (TG only)
Documentary Stamp Tax (DST) re-implemented per BIR Ruling (OT-184-2021 dated 5/20/2021)
Imposition of 12% VAT is based on Republic Act (RA) No. 10963 or the Tax Reform for Acceleration and Inclusion (TRAIN) Act
Office Order on VAT implementation took effect on January 2020

REMINDERS: Please attach validated bank advice when paying through check, if applicable.
If Assured is a withholding agent and opts to withhold 5% VAT, *attach a Certificate of Creditable Tax Withheld at Source (CCTWS).
The CCTWS or BIR Form 2307 must be an original copy and without any alteration.

REMARKS: INCREASE SUM INSURED FOR EBI AND PD DUE TO HIGH EXPOSURE OF RISK
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GOVERNMENT SERVICE INSURANCE SYSTEM

By: Received by: Date:

ANICETA G. JABIGUERO SIGNATURE OVER PRINTED NAME

Officer I, FSD
/RAEB

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