THE MERCANTILE INSURANCE CO., INC.

Mercantile Insurance Building Cor. General Luna & Beaterio Sts., Brgy. 655 Zone 69, Intramuros, Manila

Tel Nos. : (+632) 85277701 to 20 Email: gen_info@mici.com.ph Website: www.mercantile.ph

VAT REG TIN 000-825-516-000

MOTOR CAR POLICY SCHEDULE

Line : MOTOR CAR Policy Period

Subline : THIRD PARTY LIABILITY From : May 1, 2023 12:00:00 NOON
To : May 1, 2024 12:00:00 NOON
Issue Date : March 27, 2023
Policy No. : MC-TPL-CH-22-0000503-01 PREMIUM : PHP 449.44
RENEWAL Documentary Stamps : 56.18
Insured : ARIEL DACUMOS TORRES Expanded Vat : 53.93
Address : 272 SAMPAGUITA ST. SAN JOSE Connectivity Fee : 50.40
RODRIGUEZ, MONTALBAN, Rizal CIS Service Fee : 15.00
PHILIPPINES Local Government Tax : 0.45

AMOUNT DUE : PHP 625.40

Ref. Pol. No. : R

Total Sum Insured : ONE HUNDRED THOUSAND IN PHILIPPINE PESO (PHP 100,000.00)

This is a renewal for Policy No. MC-TPL-CH-22-000503-00

INSURED UNITS:

Vehicle Insured : 1 - 2019 TOYOTA AVANZA A/T

Description : 2019 TOYOTA AVANZA A/T
Model Year : 2019
Make : TOYOTA AVANZA Area of Operation : NATIONWIDE
Type of Body : WAGON Plate No. : NEC8114
Color : BLACK METALLIC Authorized Seating Capacity :
Motor/Engine No. : 1NRF488815 Unladen Weight :
Serial/Chassis No. : MHKM5EF2FKK019018 Motor Type Desc : LIGHT
Vehicle Type : UTILITY VEHICLES COC No : 1089197-22
MV File No. : 138000001116654

SCHEDULE OF SUM INSURED AND PREMIUMS

Peril/s Sum Insured Premium

Item 1
THIRD PARTY LIAB. PHP 100,000.00 PHP 449.44

WARRANTIES AND CLAUSES

SUBJECT TO DRUNKEN DRIVERS CLAUSE

E-DST CLAUSE
NO FAULT INDEMNITY ENDORSEMENT SECTION - II
Attached to and forming part of MC-TPL-CH-22-0000503-01 Page 2 of 2
THIS UNIT SHOULD NOT BE USE AS GRAB OR ANY OTHER TNVS PROVIDER.

This is a renewal for Policy No. MC-TPL-CH-22-000503-00

CHJGA THE MERCANTILE INSURANCE CO., INC.

27-MAR-23 14:09:45
803

PAR No. : MC-CH-23-007019- 00

Cred. Br. : AG
MELECIO C. MALLILLIN
Policy ID : 1506619
President

Authorized Signatory