MAPUA UNIVERSITY P.A.

APPLICATION FORM

Name of Student: Kathleen Kaye T. De Mesa Student No.: 2023103530

1. Name of Insured: Rachelle R. Tolentino

(Father/Mother or Legal Guardian)

2. Date of Birth: September 22, 1978

(Note: Not over 65 years old)

3. Occupation: Businesswoman
(see occupational exclusion)

DETAILS OF THE POLICY

• Insured - Parent and/or legal guardian of student of Mapua University

• Age Eligibility – 18 to 65 years old
• Coverage - If the father, mother or legal guardian (to be declared) of a student of Mapua
University dies due an accident, Malayan will pay Mapua University or any other school (in case
the student transferred to another school)

a. 20,000.00 per quarter or

b. 25,000.00 per trimester or
c. 30,000.00 per semester or

The actual amount of tuition fee for the quarter, trimester or semester whichever is lower, subject
to a maximum amount of P300, 000.00 or 15 quarters or 11 trimesters or 9 semesters.

The liability of the insurer shall be determined based on the number of quarter, trimester or semester for
the course less the number of quarter the student has completed.

Benefit is limited only on the remaining regular terms of the student. Additional term of a student resulting
from repetition or failure of course degree, under loading of subject and shifting to another course is not
covered.

Note: Proceeds shall be used solely for the payment of tuition fee.

Major Exclusions:
The insurance with respect to the above hazards shall not apply to:
a. loss caused directly or indirectly, wholly or partly by:
1. bacterial infections (except pyogenic infection which shall occur through an accidental cut or
wound); or infections caused by parasites.
2. medical or surgical treatment (except such as may be necessary solely by reason of injuries
covered by this policy).
3. miscarriage or pregnancy.
b. suicide or any attempt thereat (sane or insane), insanity.
c. murder and assault (provoked or unprovoked) or any attempt thereat.
d. loss occasioned by war, invasion, act of foreign enemy, hostilities or warlike operations (whether
war be declared or not), mutiny, strikes, riot, civil commotion, civil war, rebellion, revolution,
insurrection, conspiracy, military or usurped power, martial law or state of siege, seizure,
quarantine of customs regulations or nationalization by or under the order of any government or
public or local authority. This exclusion shall not be affected by any endorsement which does not
specifically refer to it, in whole or in part. The application of the exclusion referring to martial law
or state of siege or any of the events or causes which determine the proclamation or maintenance
of martial law or state of siege is hereby waived for any territorial jurisdiction of the Republic of
the Philippines.
e. nuclear radiation or radioactive contamination.
f. injury sustained while participating in professional athletics or any organized and scheduled
amateur physical contact sport, dangerous sports such as but not limited to scuba diving, bungee
jumping, skydiving or parachuting, and other extreme sports.
g. injury/death sustained while engaging in hazardous occupations such as acrobats, asylum
attendants, aviators, boilermen, detectives, drivers, explosive makers, firemen, fishermen, logger,
miner, policemen, sailors, sawmill workers, secret service personnel, woodworking machinists,
underground workers and window cleaners while performing their tasks as such, but not limited to
mountaineering requiring the use of ropes or guides, skin diving employing the use of
compressed air cylinders, racing on wheels or horseback, skydiving from device for aerial
navigation, hang gliding.
h. cave-in of mines.
i. loss or injury sustained while under the influence of alcohol or regulated/prohibited drugs,
j. the commission or attempt commission of a criminal offense.

Signature of the Insured / Conforme