PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(GOVERNMENT SERVICE INSURANCE SYSTEM)

PNR Site, Mayombo, Dagupan City, Pangasinan 2400

ACCEPTANCE AND SATISFACTION OF REPAIR

Gentlemen:

Please be advised that undersigned owner and / or duly authorized representative of

hereunder vehicle is fully satisfied and have no further claims or complains with the work done
by ________________________.

ASSURED : ______________________________
THIRD PARTY : ______________________________
UNIT : ______________________________
PLATE NO. : ______________________________

Thank you,

________________________
Signature over printed name