MAPFRE INSULAR INSURANCE CORPORATION

Ground Floor, Luz Building, 116 Gamboa Street

Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344 MI-ID: DOI-06071954-001
mbo@mapfreinsular.com, www.mapfre.com.ph

PERSONAL ACCIDENT INSURANCE POLICY

Family Provider's Accident Ins
POLICY SCHEDULE

POLICY HOLDER / INSURED DOMINGO O. IGNACIO

MAILING ADDRESS 2800 P. CELIS STREET,
PASAY CITY PHILIPPINES
INSURED IDENTIFICATION TIN-133-236-210-000
INTERMEDIARY CODE 1101

POLICY NO. 3251892000309 POLICY PREMIUM

POLICY TERM 16-Jun-2021 12:00 noon NET PREMIUM 2,018.54
16-Jun-2022 12:00 noon DOCUMENTARY STAMPS 150.00
TRANSACTION TYPE RENEWAL PREMIUM TAX 40.37
CURRENCY PHILIPPINE PESO LOCAL GOVERNMENT TAX 4.04
EFFECTIVITY DATE 16-Jun-2021 OTHER CHARGES 0.00
ISSUE DATE 14-Jun-2021
TOTAL PREMIUM DUE 2,212.95

INSURED INFORMATION
RISK NO.
NAME BIRTHDATE AGE POSITION / OCCUPATION BENEFICIARIES NET PREMIUM
1
IGNACIO, DOMINGO ROBERTOJUN-07-1954 67 RETIRED EMPLOYEE GONZALVO, TERESA 2,018.54

TABLE OF BENEFITS

BENEFITS AMOUNT OF BENEFITS

RISK NO.
1 A. ACCIDENTAL DEATH/UNPROVOKED MURDER & ASSAULT

A.1. Lump Sum Death Benefit

1,000,000.00
A.2. Funeral/Burial Assistance
50,000.00
A.3. Monthly shelter allowance for the bereaved family for one (1) year
10,000.00 /month
A.4. Educational Assistance consisting of tuition
Clothing, and daily allowance for five (5) years
Up to four (4) children between six (6) and twenty
One (21) years old (per child/per annum)
50,000.00 / child per year
A.5. Hospitalization of Dependents up to 5 years
20,000.00 /year
B. ACCIDENTAL PERMANENT DISABLEMENT

B.1. Lump Sum Disability Benefit

1,000,000.00
B.2. Monthly pension for one year
10,000.00 / month
C. MEDICAL REIMBURSEMENT
20,000.00

ASSURED'S
Page
MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

WARRANTIES AND CLAUSES

ACCIDENTAL MEDICAL REIMBURSEMENT
BENEFICIARY DESIGNATION RIDER
DISCLOSURE OF MATERIAL FACTS CLAUSE
EXTREME SPORTS EXCLUSION CLAUSE
HAZARDOUS OCCUPATION & EXTREME SPORTS EXCLUSION CLAUSE
MOTORCYCLING EXCLUSION CLAUSE
RECEIPT OF PAYMENT CLAUSE
TERRORISM EXCLUSION CLAUSE
UNPROVOKED MURDER & ASSAULT ENDORSEMENT

ASSURED'S
Page
MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

WARRANTIES AND CLAUSES WORDINGS

ACCIDENTAL MEDICAL REIMBURSEMENT
The policy will pay the actual expenses incurred resulting from covered accidental injuries sustained, not exceeding the Maximum Benefit provided under the Schedule,
for hospital surgical, nursing and other medical services or supplies required for treatment of injuries covered by the policy.

BENEFICIARY DESIGNATION RIDER

"It is hereby declared and agreed that in the absence of a named beneficiary, the beneficiary of an Insured shall be the first surviving class of the following classes of
beneficiaries, otherwise the Estate of the Insured. The Insured's:

1. Spouse
2. Children
3. Parents
4. Brothers and/or Sisters

Nothing herein contained shall be held to vary, alter, waive or change any of the terms, limits or conditions of the Policy except as herein above set forth."

DISCLOSURE OF MATERIAL FACTS CLAUSE

"Every proposer or insured when seeking new insurance or amending or renewing an existing policy must disclose any information which might influence the insurer in
deciding whether or not to accept the risk, what insuring terms to apply, or what premium to charge. The proposer or insured should also disclose all material facts relevant
to any claim filed under the policy . If the proposer or insured fails to disclose all material facts may it be known or unknown to him at the time of application, amendment or
renewal of an insurance policy, this may render the insurance contract void as of inception (from the start of the contract) and enable the insurer to disclaim any liability
(entitles the insurer not to pay your claims). If uncertain whether a fact is material, the proposer or insured should disclose it."

EXTREME SPORTS EXCLUSION CLAUSE

It is hereby declared and agreed that this policy shall not cover death, disablement, or injuries: Happening or Occasioned by whilst the Insured is performing, extremely
thrilling and hazardous sports either as a trainer or participant of Skiing, Snowboarding, Skateboarding, Dirt biking, 4x4 off-road challenge, Hang gliding, Mountain
climbing, Scuba diving, Parasailing, Bungee jumping, Parachuting, Hang gliding. Tree Top Adventure of all sorts, Base jumping, Body boarding, Canoeing, Cliff jumping,
Extreme motorsports (supercross, motocross, freestyle motocross), Free running, Hang gliding, Jet Skis, motocross), Free running, Hang gliding, Jet Skis, Kite Surfing,
Extreme Biking (BMX & Downhill), Kite Surfing, Extreme Biking (BMX & Downhill), Paragliding, Rock Climbing, Sand Boarding, Snow Paragliding, Rock Climbing, Sand
Boarding, Snow Boarding, Skiing, Surfing, White water rafting, Wing Boarding, Skiing, Surfing, White water rafting, Wing suit sky diving, and other activities of similar suit
sky diving, and other activities of similar nature and degree of sports hazards.
nature and degree of sports hazards.

HAZARDOUS OCCUPATION & EXTREME SPORTS EXCLUSION CLAUSE

It is hereby declared and agreed that this policy shall not cover death, disablement, or injuries:

1. Occurring whilst the Insured is performing or attending his/her profession, occupation or duties as Bodyguards, Security guards, Policemen and other authorities with
police powers, Aircraft flight crew, Arrastre workers/operators, Ship crew members, Pilot or Flight Attendants, Army personnel (members of the Armed Forces), Scuba
divers, Mountain climbing instructors, Surfing instructors, Race drivers, Motocross riders, Stuntmen, Explosive makers, handlers or custodians, Firemen, Sailors (member
s of the Naval Forces), Underground workers, Miners, Disaster & Calamity Rescue Team or crew, Horse jockeys, Martial artists as a trainer or student, Steeplejacks or
window cleaners, Tree climber, coconut/tuba gatherers, Waste disposal/ leaching chamber workers, Linemen , and other professions or occupations of similar nature and
degree of occupational hazards.

2. Happening or Occasioned by whilst the Insured is performing, extremely thrilling and hazardous sports either as a trainer or participant of Skiing, Snowboarding,
Skateboarding, Dirt biking, 4x4 off-road challenge, Hang gliding, Mountain climbing, Scuba diving, Parasailing, Bungee jumping, Parachuting, Hang gliding. Tree Top
Adventure of all sorts, Base jumping, Body boarding, Canoeing, Cliff jumping, Extreme motorsports (supercross, motocross, freestyle motocross), Free running, Hang
gliding, Jet Skis, Kite Surfing, Extreme Biking (BMX & Downhill), Paragliding, Rock Climbing, Sand Boarding, Snow Boarding, Skiing, Surfing, White water rafting, Wings
suit sky diving, and other activities of similar nature and degree of sports hazards.

MOTORCYCLING EXCLUSION CLAUSE

It is hereby declared and agreed that provision 1 (d) in the policy condition is deemed amended to read as follows:
This policy shall not extend to cover:
Death or disablement consequent upon the Insured is engaging in racing of all kinds, motor cycling including pillion riding and/ or driving a motorcycle, motor scooter,
motor bicycle or any other two-wheeled motor vehicle having one or more ridings saddles.

RECEIPT OF PAYMENT CLAUSE

Except only in those specific cases where corresponding rules and regulations which are now or may hereafter be in force Provide for the payment of the stipulated
premiums in periodic Installments at fixed percentages, it is here by agreed, Declared and warranted that this policy shall be deemed Effective, valid and binding uponthe
insurer only when the Premiums therefore have actually been paid in full and duly acknowledged in a receipt signed by any authorized official or representative/agent of
the company.

TERRORISM EXCLUSION CLAUSE

Notwithstanding any provision to the contrary within this insurance or any endorsement thereto, it is agreed that this insurance excludes loss, damage, cost or expense of
whatsoever nature directly or indirectly caused by, resulting from or in connection with any act of terrorism regardless of any other cause or event contributing concurrently
or in any other sequence to the loss.

For the purpose of this endorsement, an act of terrorism means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or
group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s), committed for political, religious, ideological or

ASSURED'S
Page
 MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident
POLICY NO. 3251892000309
similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

This endorsement also excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken
in controlling, preventing, suppressing or in any way relating to any act of terrorism.

If the Underwriters allege that by reason of this exclusion,any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be
upon the Assured.

In the event any portion of this endorsement is found to be invalid or unenforceable,the remainder shall remain in full force and effect.

UNPROVOKED MURDER & ASSAULT ENDORSEMENT

"It is hereby declared and agreed that this policy extends to cover injury or death if the Insured was intentionally injured, assaulted, or killed by another person provided
that such incident shall not have been provoked by the Insured and shall not have occurred in any of the following geographical areas, including their cities, towns, barrios
and barangays:
a) South Basilan
b) Entire Samar
c) Sultan Kudarat
d) Sulu Archipelago
e) Lanao del Norte/Sur
f) North/South Cotobato
g) Zamboanga Peninsula
Nothing contained herein shall be held to vary, alter, waive, or change any of the terms, limits, or conditions of the policy.

ANNEX
NAME:(SURNAME, FIRST NAME, MIDDLE NAME)
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY: (MM/DD/YYYY)

NAME:
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY:

NAME:
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY:

(Subject to the terms, conditions, warranties and clauses of the MAPFRE INSULAR INSURANCE CORPORATION Family Provider's Accident Ins Policy)
IN WITNESS WHEREOF, The Company caused this policy to be signed by its duly authorized officer/representative at Legaspi Village, Makati City, Philippines this 14th day of June 2021.
IMPORTANT NOTICE:
The Insurance Commissioner, with offices in Manila, Cebu and Davao is the Government official in charge of the faithful execution and enforcement of all laws relating to insurance and has supervision over
insurance companies. He is ready at all times to render assistance in settling any controversy between an insurance company and a policy holder relating to insurance matters.
Documentary Stamps to the value of 150.00 have been affixed to the premium register.

CONFORME

TIRSO C. ABAD
ASSURED'S SIGNATURE PRESIDENT AND CEO
ASSURED'S
Page
MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

POLICY HOLDER / INSURED DOMINGO O. IGNACIO

MAILING ADDRESS 2800 P. CELIS STREET,
PASAY CITY PHILIPPINES
INSURED IDENTIFICATION TIN-133-236-210-000
INTERMEDIARY CODE 1101

POLICY NO. 3251892000309 POLICY PREMIUM

POLICY TERM 16-Jun-2021 12:00 noon NET PREMIUM 2,018.54
16-Jun-2022 12:00 noon DOCUMENTARY STAMPS 150.00
TRANSACTION TYPE RENEWAL PREMIUM TAX 40.37
CURRENCY PHILIPPINE PESO LOCAL GOVERNMENT TAX 4.04
EFFECTIVITY DATE 16-Jun-2021 OTHER CHARGES 0.00
ISSUE DATE 14-Jun-2021
TOTAL PREMIUM DUE 2,212.95

INSURED INFORMATION
RISK NO.
NAME BIRTHDATE AGE POSITION / OCCUPATION BENEFICIARIES NET PREMIUM
1
IGNACIO, DOMINGO ROBERTOJUN-07-1954 67 RETIRED EMPLOYEE GONZALVO, TERESA 2,018.54

TABLE OF BENEFITS

BENEFITS AMOUNT OF BENEFITS

RISK NO.
1 A. ACCIDENTAL DEATH/UNPROVOKED MURDER & ASSAULT

A.1. Lump Sum Death Benefit

1,000,000.00
A.2. Funeral/Burial Assistance
50,000.00
A.3. Monthly shelter allowance for the bereaved family for one (1) year
10,000.00 /month
A.4. Educational Assistance consisting of tuition
Clothing, and daily allowance for five (5) years
Up to four (4) children between six (6) and twenty
One (21) years old (per child/per annum)
50,000.00 / child per year
A.5. Hospitalization of Dependents up to 5 years
20,000.00 /year
B. ACCIDENTAL PERMANENT DISABLEMENT

B.1. Lump Sum Disability Benefit

1,000,000.00
B.2. Monthly pension for one year
10,000.00 / month
C. MEDICAL REIMBURSEMENT
20,000.00

AGENT'S
Page
MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

POLICY NO.

WARRANTIES AND CLAUSES

ACCIDENTAL MEDICAL REIMBURSEMENT

BENEFICIARY DESIGNATION RIDER
DISCLOSURE OF MATERIAL FACTS CLAUSE
EXTREME SPORTS EXCLUSION CLAUSE
HAZARDOUS OCCUPATION & EXTREME SPORTS EXCLUSION CLAUSE
MOTORCYCLING EXCLUSION CLAUSE
RECEIPT OF PAYMENT CLAUSE
TERRORISM EXCLUSION CLAUSE
UNPROVOKED MURDER & ASSAULT ENDORSEMENT

AGENT'S
Page
MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

POLICY NO.
WARRANTIES AND CLAUSES WORDINGS
ACCIDENTAL MEDICAL REIMBURSEMENT
The policy will pay the actual expenses incurred resulting from covered accidental injuries sustained, not exceeding the Maximum Benefit provided under the Schedule,
for hospital surgical, nursing and other medical services or supplies required for treatment of injuries covered by the policy.

BENEFICIARY DESIGNATION RIDER

"It is hereby declared and agreed that in the absence of a named beneficiary, the beneficiary of an Insured shall be the first surviving class of the following classes of
beneficiaries, otherwise the Estate of the Insured. The Insured's:

1. Spouse
2. Children
3. Parents
4. Brothers and/or Sisters

Nothing herein contained shall be held to vary, alter, waive or change any of the terms, limits or conditions of the Policy except as herein above set forth."

DISCLOSURE OF MATERIAL FACTS CLAUSE

"Every proposer or insured when seeking new insurance or amending or renewing an existing policy must disclose any information which might influence the insurer in
deciding whether or not to accept the risk, what insuring terms to apply, or what premium to charge. The proposer or insured should also disclose all material facts relevant
to any claim filed under the policy . If the proposer or insured fails to disclose all material facts may it be known or unknown to him at the time of application, amendment or
renewal of an insurance policy, this may render the insurance contract void as of inception (from the start of the contract) and enable the insurer to disclaim any liability
(entitles the insurer not to pay your claims). If uncertain whether a fact is material, the proposer or insured should disclose it."

EXTREME SPORTS EXCLUSION CLAUSE

It is hereby declared and agreed that this policy shall not cover death, disablement, or injuries: Happening or Occasioned by whilst the Insured is performing, extremely
thrilling and hazardous sports either as a trainer or participant of Skiing, Snowboarding, Skateboarding, Dirt biking, 4x4 off-road challenge, Hang gliding, Mountain
climbing, Scuba diving, Parasailing, Bungee jumping, Parachuting, Hang gliding. Tree Top Adventure of all sorts, Base jumping, Body boarding, Canoeing, Cliff jumping,
Extreme motorsports (supercross, motocross, freestyle motocross), Free running, Hang gliding, Jet Skis, motocross), Free running, Hang gliding, Jet Skis, Kite Surfing,
Extreme Biking (BMX & Downhill), Kite Surfing, Extreme Biking (BMX & Downhill), Paragliding, Rock Climbing, Sand Boarding, Snow Paragliding, Rock Climbing, Sand
Boarding, Snow Boarding, Skiing, Surfing, White water rafting, Wing Boarding, Skiing, Surfing, White water rafting, Wing suit sky diving, and other activities of similar suit
sky diving, and other activities of similar nature and degree of sports hazards.
nature and degree of sports hazards.

HAZARDOUS OCCUPATION & EXTREME SPORTS EXCLUSION CLAUSE

It is hereby declared and agreed that this policy shall not cover death, disablement, or injuries:

1. Occurring whilst the Insured is performing or attending his/her profession, occupation or duties as Bodyguards, Security guards, Policemen and other authorities with
police powers, Aircraft flight crew, Arrastre workers/operators, Ship crew members, Pilot or Flight Attendants, Army personnel (members of the Armed Forces), Scuba
divers, Mountain climbing instructors, Surfing instructors, Race drivers, Motocross riders, Stuntmen, Explosive makers, handlers or custodians, Firemen, Sailors (member
s of the Naval Forces), Underground workers, Miners, Disaster & Calamity Rescue Team or crew, Horse jockeys, Martial artists as a trainer or student, Steeplejacks or
window cleaners, Tree climber, coconut/tuba gatherers, Waste disposal/ leaching chamber workers, Linemen , and other professions or occupations of similar nature and
degree of occupational hazards.

2. Happening or Occasioned by whilst the Insured is performing, extremely thrilling and hazardous sports either as a trainer or participant of Skiing, Snowboarding,
Skateboarding, Dirt biking, 4x4 off-road challenge, Hang gliding, Mountain climbing, Scuba diving, Parasailing, Bungee jumping, Parachuting, Hang gliding. Tree Top
Adventure of all sorts, Base jumping, Body boarding, Canoeing, Cliff jumping, Extreme motorsports (supercross, motocross, freestyle motocross), Free running, Hang
gliding, Jet Skis, Kite Surfing, Extreme Biking (BMX & Downhill), Paragliding, Rock Climbing, Sand Boarding, Snow Boarding, Skiing, Surfing, White water rafting, Wings
suit sky diving, and other activities of similar nature and degree of sports hazards.

MOTORCYCLING EXCLUSION CLAUSE

It is hereby declared and agreed that provision 1 (d) in the policy condition is deemed amended to read as follows:
This policy shall not extend to cover:
Death or disablement consequent upon the Insured is engaging in racing of all kinds, motor cycling including pillion riding and/ or driving a motorcycle, motor scooter,
motor bicycle or any other two-wheeled motor vehicle having one or more ridings saddles.

RECEIPT OF PAYMENT CLAUSE

Except only in those specific cases where corresponding rules and regulations which are now or may hereafter be in force Provide for the payment of the stipulated
premiums in periodic Installments at fixed percentages, it is here by agreed, Declared and warranted that this policy shall be deemed Effective, valid and binding uponthe
insurer only when the Premiums therefore have actually been paid in full and duly acknowledged in a receipt signed by any authorized official or representative/agent of
the company.

TERRORISM EXCLUSION CLAUSE

Notwithstanding any provision to the contrary within this insurance or any endorsement thereto, it is agreed that this insurance excludes loss, damage, cost or expense of
whatsoever nature directly or indirectly caused by, resulting from or in connection with any act of terrorism regardless of any other cause or event contributing concurrently
or in any other sequence to the loss.

For the purpose of this endorsement, an act of terrorism means an act, including but not limited to the use of force or violence and/or the threat thereof, of any person or
group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s), committed for political, religious, ideological or

AGENT'S
Page
 MAPFRE INSULAR INSURANCE
CORPORATION
Ground Floor, Luz Building, 116 Gamboa
Street Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
MI-ID: DOI-06071954-

PERSONAL ACCIDENT INSURANCE

POLICY
Family Provider's Accident

POLICY NO.
similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

This endorsement also excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken
in controlling, preventing, suppressing or in any way relating to any act of terrorism.

If the Underwriters allege that by reason of this exclusion,any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be
upon the Assured.

In the event any portion of this endorsement is found to be invalid or unenforceable,the remainder shall remain in full force and effect.

UNPROVOKED MURDER & ASSAULT ENDORSEMENT

"It is hereby declared and agreed that this policy extends to cover injury or death if the Insured was intentionally injured, assaulted, or killed by another person provided
that such incident shall not have been provoked by the Insured and shall not have occurred in any of the following geographical areas, including their cities, towns, barrios
and barangays:
a) South Basilan
b) Entire Samar
c) Sultan Kudarat
d) Sulu Archipelago
e) Lanao del Norte/Sur
f) North/South Cotobato
g) Zamboanga Peninsula
Nothing contained herein shall be held to vary, alter, waive, or change any of the terms, limits, or conditions of the policy.

ANNEX
NAME:(SURNAME, FIRST NAME, MIDDLE NAME)
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY: (MM/DD/YYYY)

NAME:
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY:

NAME:
RELATIONSHIP TO PRIMARY INSURED:
BIRTHDAY:

(Subject to the terms, conditions, warranties and clauses of the MAPFRE INSULAR INSURANCE CORPORATION Family Provider's Accident Ins Policy)
IN WITNESS WHEREOF, The Company caused this policy to be signed by its duly authorized officer/representative at Legaspi Village, Makati City, Philippines this 14th day of June 2021.
IMPORTANT NOTICE:
The Insurance Commissioner, with offices in Manila, Cebu and Davao is the Government official in charge of the faithful execution and enforcement of all laws relating to insurance and has supervision over
insurance companies. He is ready at all times to render assistance in settling any controversy between an insurance company and a policy holder relating to insurance matters.
Documentary Stamps to the value of 150.00 have been affixed to the premium register.

CONFORME

TIRSO C. ABAD
ASSURED'S SIGNATURE PRESIDENT AND CEO
AGENT'S
Page
MAPFRE INSULAR INSURANCE CORPORATION
Ground Floor, Luz Building, 116 Gamboa Street
Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
mbo@mapfreinsular.com, www.mapfre.com.ph

STATEMENT OF ACCOUNT
NUMBER: DATE: MBO-11000102689 14 Jun 2021
Customer No. TIN-133-236-210-000 PAYMENT REF. NO.: DUE DATE:
0008805260716216
PAYMENT MODE:
NO. OF PAYMENT: 16 Jun 2021 ANNUAL
DOMINGO O. IGNACIO 1 of 1
2800 P. CELIS STREET,
PASAY CITY PHILIPPINES

POLICY NO: 3251892000309

Term of Insurance: 16 Jun 2021 - 16 Jun 2022
Effectivity Date: 16 Jun 2021
Interest Insured: Declared Person/s PREMIUM PHP 2,018.54
DOCUMENTARY STAMPS 150.00
PREMIUM TAX 40.37
AVAILABLE PAYMENT CHANNELS
LOCAL GOV'T TAX 4.04
• Over-the-counter and Online Biller: BPI | BDO | Union Bank | Security Bank 0.00
OTHER CHARGES
• Automated Teller Machine: Security Bank
• BAYAD CENTER TOTAL AMOUNT DUE PHP 2,212.95
• MAPFRE Insular Offices (for Debit and Credit card payments
only) IMPORTANT REMINDERS
• When paying, please use the 16-digit Payment Reference No. 0008805260716216
• For cheque payment, please make cheque payable to MAPFRE INSULAR
INSURANCE CORPORATION. Please write the invoice number and your
telephone number at the back of the cheque.
• An OFFICIAL RECEIPT will be mailed to you at the earliest date. Please notify
the company if you do not receive the Official Receipt 30 days after payment
date.
• INSURANCE COVERAGE WILL NOT TAKE EFFECT IF PREMIUM WAS PAID
AFTER OCCURRENCE OF A LOSS AS PER SECTION 77 OF THE INSURANCE

Pseudo Supplier: Mapfre Insular Insurance Corporation

Mapfre Insular Corporate Center, Acacia Ave. Madrigal Business
Park, Ayala Alabang, Muntinlupa City
VAT Registration 000-491-771-004
Accreditation Date: June 17, 2019
BIR Permit to Use (PTU) Number 1906-0125-PTU-CAS-000547
Internal Series # 11000000001 - 99999999999

THIS INVOICE SHALL BE VALID FOR FIVE (5) YEARS FROM THE DATE OF THE PERMIT TO USE
THIS DOCUMENT IS NOT VALID TO CLAIM INPUT TAX
ASSURED'S COPY
MAPFRE INSULAR INSURANCE CORPORATION
Ground Floor, Luz Building, 116 Gamboa Street
Legaspi Village, Makati City
VAT REG TIN 000-491-771-004
TEL (2) 8876-4331 - FAX (2) 8876-4344
mbo@mapfreinsular.com, www.mapfre.com.ph

STATEMENT OF ACCOUNT
Customer No. TIN-133-236-210-000 NUMBER: DATE: MBO-11000102689 14 Jun 2021
PAYMENT REF. NO.: DUE DATE:
0008805260716216
PAYMENT MODE:
NO. OF PAYMENT: 16 Jun 2021 ANNUAL
DOMINGO O. IGNACIO
1 of 1
2800 P. CELIS STREET,
PASAY CITY PHILIPPINES

POLICY NO: 3251892000309

Term of Insurance: 16 Jun 2021 - 16 Jun 2022
Effectivity Date: 16 Jun 2021
Interest Insured: Declared Person/s

Pseudo Supplier: Mapfre Insular Insurance Corporation

Mapfre Insular Corporate Center, Acacia Ave. Madrigal Business Park, Ayala Alabang, Muntinlupa City
VAT Registration 000-491-771-004
Accreditation Date: June 17, 2019
BIR Permit to Use (PTU) Number 1906-0125-PTU-CAS-000547
• MAPFRE Insular Offices (for Debit and Credit card payments
only) IMPORTANT REMINDERS
• When paying, please use the 16-digit Payment Reference No. 0008805260716216
• For cheque payment, please make cheque payable to MAPFRE INSULAR
INSURANCE CORPORATION. Please write the invoice number and your
telephone number at the back of the cheque.
• An OFFICIAL RECEIPT will be mailed to you at the earliest date. Please notify
the company if you do not receive the Official Receipt 30 days after payment NT'S COPY
date.
• INSURANCE COVERAGE WILL NOT TAKE EFFECT IF PREMIUM WAS PAID
AFTER OCCURRENCE OF A LOSS AS PER SECTION 77 OF THE INSURANCE

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FI
V
E
(5

Y
E
A
R
S
F
R
O
M
T
H
E
D
A
T
E
O
F
T
H
E
P
E
R
MI
T
T
O
U
S
E
T
HI
S
D
O
C
U
M
E
N
T
IS
N
O
T
V
A
LI
D
T
O
C
L
AI
M
IN
P
U
T
T
A
X
A
G
E