Professional Documents
Culture Documents
Domingo O. Ignacio - 3251892000309
Domingo O. Ignacio - 3251892000309
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
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-
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-
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."
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.
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-
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.
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-
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
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-
POLICY NO.
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-
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.
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."
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.
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-
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.
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
[email protected], 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
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
[email protected], 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
T
HI
S
IN
V
OI
C
E
S
H
A
LL
B
E
V
A
LI
D
F
O
R
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