15th Floor, Sage House, 110 V. A.

Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT
“ORIGINAL”
CONFIRMATION OF COVER
NON-LAND TRANSPORTATION OPERATORS VEHICLE
NAME AND ADDRESS OF INSURED AUTHENTICATION NO. POLICY NO.
VIRGILIO JR. LANSANG FAJARDO 064ALICD2502 PCOC185743
BLK 3 LOT 9 JAVA ST. CYBERGREENS SUBDIVISION BUSINESS / PROFESSION CONFIRMATION OF COVER
SANTIAGO
0649994988
GENERAL TRIAS CAVITE
4107 DATE ISSUED OFFICIAL RECEIPT NO.
JUNE 19, 2025

PERIOD OF INSURANCE
FROM 12:00 NOON TO 12:00 NOON
JULY 01, 2025 JULY 01, 2026

SCHEDULE OF VEHICLE
MODEL MAKE TYPE OF BODY COLOR M.V. FILE NO.
2017 AVANZA 1.3 E A/T TOYOTA WAGON METALLIC GRAY 040100000451750
PLATE NO. SERIAL / CHASSIS NO. MOTOR NO. AUTHORIZED CAPACITY UNLADEN WEIGHT
DAE9876 MHKM5EF2FHK010058 1NRF300402 7
Kgs.

SECTION I / II A
M LIMITS OF LIABILITY P 200,000.00
O
THIRD PARTY LIABILITY U
N PREMIUMS PAID
SUBJECT TO THE SCHEDULE OF INDEMNITIES SHOWN BELOW
T (Inclusive of Taxes) P 606.00
S

This Confirmation of Cover is evidence of the policy of insurance required under

Chapter VI - Compulsory Motor Vehicle Insurance of the Insurance Code as amended Reynaldo M. Saria, SAVP - Underwriting
by Presidential Decree No. 1814 Authorized Signature

SCHEDULE OF INDEMNITIES FOR BODILY INJURY AND/OR DEATH

The following schedule of indemnities shall be observed in the settlement of claims for death, bodily injuries, professional fees and hospital charges for
services rendered to, traffic accident victims under the Compulsory Motor Vehicle Liability Insurance policy.

A. DEATH INDEMNITY P 200,000.00 C. PERMANENT DISABLEMENT

including Burial and Funeral Expenses Loss Of or Loss of Use of: AMOUNT
B. BODILY INJURIES AND FRACTURES Two Limbs P 50,000.00
Both Hands, or All Fingers & 50,000.00
Types of Accommodation Maximum Both Thumbs
or Professional Services Rendered Reimbursable Fees Both Feet 50,000.00
Attendance Extended and/or Charges One Hand and one Foot 50,000.00
Sight of both eyes 50,000.00
1. Hospital Rooms Maximum of 45 days per accident P 500.00/day Injuries resulting in being 50,000.00
Laboratory Examination fees, permanently bedridden
2,000.00
X-rays Any other injury causing 50,000.00
2. Surgical Expenses Major Operation 7,500.00 permanent total disablement
Arm at or above elbow 20,000.00
Medium Operation 5,000.00
Arm between elbow and wrist 15,000.00
Minor Operation 1,500.00 Hand 15,000.00
3. Anaesthesiologist’s Fees Major Operation 2,500.00 Four fingers and thumb of one 15,000.00
Medium Operation 2,000.00 hand
Four fingers 12,000.00
Minor Operation 500.00
Leg at or above knee 20,000.00
4. Operating Room Major Operation 1,500.00 Leg below knee 15,000.00
Medium Operation 1,000.00 One foot 15,000.00
Minor Operation 500.00 All toes of one foot 10,000.00
5. Medical Expenses For daily visits of Practitioner or Thumb 8,000.00
400.00/day Index Finger 6,000.00
Specialists
The total amount of medical Sight of one Eye 20,000.00
expenses must not exceed 5,000.00 Hearing-both Ears 30,000.00
(For a single period of Hearing-one Ear 15,000.00
confinement) D. OTHER INCIDENTAL EXPENSES
6. Drugs and Medicines Actual value of drugs and The Company will pay all pertinent and reasonable expenses
20,000.00
medicines used but not to exceed incurred in connection with the accident not provided under
this Schedule of Indemnities (A), (B), and (C), subject to a
7. Ambulance Actual amount charged for maximum amount of Ten Thousand Pesos (P10,000.00) but
ambulance transport but not to 1,500.00 in no case shall the company’s aggregate payment exceed
exceed the overall Limits of Liability under Sections I and II.

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 policyholder relating to insurance matters.
Makati City 19 June 25
WHEREAS THE INSURED, by his corresponding proposal and declaration, and which shall be the basis of this
Contract and deemed incorporated herein, has applied to the Company for the Insurance hereinafter contained,
subject to the payment of the Premium as consideration for such insurance.
NOW THIS POLICY WITNESSETH:

That, in respect of events occurring during the period of insurance and subject to the terms, exceptions and
conditions contained herein or endorsed hereon (hereinafter collectively referred to as the Terms of this Policy):

SECTION I - LIABILITY TO THE PUBLIC

1. The Company will pay all sums necessary to discharge liability of the Insured, arising from all expenses
and damages directly resulting from any bodily injury and/or death to any Third Party (excluding all moral,
exemplary and other incidental damages, expenses and loss of income) in an accident caused by the use of
the Scheduled Vehicle, provided that the Insured’s liability shall have first been determined, but not exceeding
in the aggregate P200,000 per occurrence or any one occurrence, regardless of the number of individual
claims.
2. In terms of and subject to the limitations of this Policy, the Company will indemnify: —
(a) Any authorized Driver who is driving the Scheduled Vehicle, provided that he: -
(i) Observes, fulfills, and be subject to the Terms of this Policy insofar as they can apply;
(ii) is not entitled to indemnity under any other policy subject, however, to Condition No. 8 of the Conditions
Applicable to All Sections.
(b) the Insured whilst personally driving a private motor car not belonging to him and not hired to him under a
hire purchase agreement
3. In the event of the death of any person entitled to indemnity under this Policy the Company will, in respect of
the liability incurred to such person indemnify his personal representatives in terms of, and subject to the terms
and conditions hereof.
4. In the event of accident involving indemnity under this Policy to more than one person, the Limits of Liability shall
not exceed the aggregate amount so specified by law to all persons to be indemnified. Should indemnification
both to liability of the Insured and that of another party (as provided under Authorized Driver) be provable, the
Insured’s shall have prior right thereto.
5. Unless the Insured objects, the Company shall:—
(a) arrange for representation at any inquest or investigation in respect of any death which may be the subject
of indemnity under this Section;
(b) undertake the defense in the Insurance Commission under Section 385 of the Insurance Code, or in any
court of law, for alleged offenses causing, or relating to, any event which may be the subject of indemnity
under this Section.

SCHEDULE OF INDEMNITIES FOR BODILY INJURY AND/OR DEATH

The following schedule of indemnities shall be observed in the settlement of claims for death, bodily injuries,
professional fees and hospital charges for services rendered to, traffic accident victims under the Compulsory
Motor Vehicle Liability Insurance policy.

A. DEATH INDEMNITY P 200,000.00

including Burial and Funeral Expenses
B. BODILY INJURIES AND FRACTURES

Types of Accommodation or Professional Maximum Reimbursable

Services Rendered
Attendance Extended Fees and/or Charges

1. Hospital Rooms Maximum of 45 days per accident P 500.00/day

Laboratory Examination, fees, x-rays 2,000.00

2. Surgical Expenses Major Operation 7,500.00

Medium Operation 5,000.00
Minor Operation 1,500.00
3. Anaesthesiologist’s Fees Major Operation 2,500.00
Medium Operation 2,000.00
Minor Operation 500.00

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | PRIVATE CAR POLICY (CTPL Only) 2
4. Operating Room Major Operation 1,500.00
Medium Operation 1,000.00
Minor Operation 500.00

5. Medical Expenses For daily visits of Practitioner or 400.00/day

specialists
The total amount of medical expenses 5,000.00
must not exceed
(For a single period of confinement)

6. Drugs and Medicines Actual value of drugs and medicines 20,000.00

used but not to exceed

7. Ambulance Actual amount charged for ambulance 1,500.00

transport but not to exceed

C. PERMANENT DISABLEMENT
Loss Of or Loss of Use of: AMOUNT

Two Limbs P 50,000.00

Both Hands, or All Fingers & Both Thumbs 50,000.00
Both Feet 50,000.00
One Hand and One Foot 50,000.00
Sight of Both Eyes 50,000.00
Injuries Resulting in being permanently bedridden 50,000.00
Any other injury causing permanent total disablement 50,000.00
Arm at or above elbow 20,000.00
Arm between elbow and wrist 15,000.00
Hand 15,000.00
Four Fingers and Thumb of one Hand 15,000.00
Four Fingers 12,000.00
Leg at or above knee 20,000.00
Leg below knee 15,000.00
One Foot 15,000.00
All Toes of one foot 10,000.00
Thumb 8,000.00
Index Finger 6,000.00
Sight of One Eye 20,000.00
Hearing - Both Ears 30,000.00
Hearing - One Ear 15,000.00

D. OTHER INCIDENTAL EXPENSES

The Company will pay all pertinent and reasonable expenses incurred in connection with the accident not
provided under this Schedule of Indemnities (A), (B), and (C), subject to a maximum amount of Ten Thousand
Pesos P10,000.00 but in no case shall the company’s aggregate payment exceed the overall Limits of Liability
under Sections I and II.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | PRIVATE CAR POLICY (CTPL Only) 3
 SECTION II - NO FAULT INDEMNITY

The Company will pay any claim for bodily injury and/or death to any THIRD PARTY without the necessity of
proving fault or negligence of any kind, provided that,
(a) the total indemnity in respect of any one THIRD PARTY shall not exceed Thirty Thousand Pesos (P30,000),
subject to the foregoing Schedule of Indemnities in case of death or physical injury, without prejudice to
the claimant from pursuing his claim further, in which case he shall not be required or compelled by the
Company to execute any Quit Claim or document releasing it from liability under the policy of insurance.
(b) the following proofs of loss, when submitted under oath, shall be sufficient evidence to substantiate the
claim;—
(i) Police report of accident or any evidence sufficient to establish the accident, and
(ii) Medical report and evidence of medical or hospital expenses and/or;
(iii) Death Certificate and evidence sufficient to establish the proper payee.

GENERAL EXCEPTIONS

The Company shall not be liable under any Section of this Policy in respect of: -
1. Any accident, or liability caused, or incurred
(a) outside the Republic of the Philippines;
(b) whilst the Scheduled Vehicle is:
(i) being used otherwise than in accordance with the limitations as to use;
(ii) being driven by any person other than an Authorized Driver;
(iii) on board a sea vessel on inter-island transit.

2. Any liability which attached by virtue of an agreement but which would not have attached in the absence
of such agreement, except liability arising out of an on the spot agreement or amicable settlement of minor
accident to avoid impairing the flow of traffic.

3. Except in respect of claims arising under Sections I and II of this Policy, any accident, loss, damage or liability
directly or indirectly, proximately or remotely occasioned by, contributed to by or traceable to, or arising out of,
or in connection with flood, typhoon, hurricane, volcanic eruption, earthquake or other convulsion of nature,
invasion, the act of foreign enemies, hostilities or warlike operations (whether war be declared or not), strike,
riot, civil commotion, mutiny, rebellion, insurrection, military or usurped power, or by any direct or indirect
consequences of any of the said occurrences and in the event of any claim hereunder, the Insured shall prove
that the accident, loss or damage or liability arose independently of, and was in no way connected with, or
occasioned by, or contributed to, any of the said occurrences, or any consequence thereof, and in default of
such proof, the Company shall not be liable to make any payment in respect of such a claim.

4. Any sum which the Insured would have been entitled to recover from any party but for an agreement between
the Insured and such party.

5. Bodily injury and/or death to any person in the employ of the Insured arisng out of and in the course of such
employment, or bodily injury and/or death to any member of the Insured’s household who is riding in the
Scheduled Vehicle.

DEFINITIONS

1. MOTOR VEHICLE is any vehicle as defined in Section Three, Paragraph (a) of Republic Act - Numbered Four
Thousand One Hundred Thirty-Six, otherwise known as the “Land Transportation and Traffic Code”.

2. THIRD PARTY is any person other than a PASSENGER as defined in the law and shall also exclude a member
of the household, or a member of the family within the second degree of consanguinity or affinity, of a motor
vehicle owner or his employee in respect of death, bodily injury or damage to property arising out of and in the
course of employment.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | PRIVATE CAR POLICY (CTPL Only) 4
 CONDITIONS APPLICABLE TO ALL SECTIONS

1. This Policy and the Schedule shall be read together, as one contract, and any word or expression to which
a specific meaning has been attached in any part of this Policy or of the Schedule shall bear such specific
meaning wherever it may appear.

2. Every notice or communication to be given or made under this Policy shall be delivered in writing to the
Company.

3. The Insured shall maintain the Scheduled Vehicle in efficient condition, and the Company shall have at all
times free and full access to examine the Scheduled Vehicle or any part thereof or any driver or employee of
the Insured.

4. In the event of any accident which may give rise to a claim under this Policy, the Insured shall, as soon as
possible, give notice thereof to the Company with full particulars. Every letter, claim, writ, summons and
process shall be notified or forwarded to the Company immediately on receipt. Notice shall also be given to
the Company immediately as soon as the Insured shall have knowledge of any impending prosecution, inquest
or fatal inquiry in connection with any such occurrence. In case of carnapping or other criminal act which may
give rise to a claim under this Policy, the Insured shall give immediate notice to the Police and cooperate with
the Company in securing the conviction of the offender.

5. Without prejudice to No. 2 of the General Exceptions, no admission, offer, promise or payment shall be made
by or on behalf of the Insured without the written consent of the Company which shall be entitled to take over
the conduct in his name the defense or settlement of any claim, or to prosecute in his name for its own benefit
any claim for indemnity or damages or otherwise, but shall not exercise any discretion prejudicial to the interest
of the Insured in the conduct of any proceedings in the settlement of any claim, and the Insured shall give all
such information and assistance as the Company may require. If the Company shall with the consent of the
Insured make any payment in settlement of any claim and such payment includes any amount not covered by
this Policy, the Insured shall repay the Company the amount not so covered.

6. At any time after the happening of any event giving rise to a claim or series of claims under this Policy,
the Company may pay to the Insured and the Third Party claimant jointly the full amount of the Company’s
liability and relinquish the conduct of any defense, settlement or proceedings and the Company shall not be
responsible for any damage alleged to have been caused to the Insured in consequence of any alleged action
or omission of the Company in connection with such defense, settlement or proceedings or of the Company
relinquishing such conduct, nor shall the Company be liable for any costs or expenses whatsoever incurred by
the Insured or any claimant or other person after the Company shall have so relinquished.

7. The Company may cancel this Policy in accordance with Section 64, 65, and 380 of the Insurance Code, in
which case, the Company shall thereupon return to the insured premiums paid less pro rata portion thereof for
the period when the Policy has been in force. The Insured may, at any time, cancel the Policy by surrendering
it to the Company and (provided no claim has arisen during the then current period of insurance) the Insured
shall be entitled to a return of the premium at the Company’s Short Period Rates for the period when the
Policy has been in force. However, in respect of Sections I and II, the cancellation made by the Insured shall
not be effective unless he has secured a similar policy of insurance or surety bond to replace the policy to
be cancelled or make a cash deposit in sufficient amount with the Commissioner and without any gap file
within five (5) working days from the date of cancellation the required documentation with the Bureau of Land
Transportation in accordance with Section 381 of the Insurance Code.

8. If, at the time any claim arises under this Policy, there is any other insurance covering the same loss, damage
or liability, the Company shall not be liable to pay or contribute more than its ratable proportion of any loss,
damage, compensation, costs or expenses. Provided always that nothing in this Condition shall impose on
the Company any liability from which, but for this Condition, it would have been relieved under proviso (ii) of
Section 1-2 of this Policy.

9. In case of any dispute in the enforcement of the provisions of Section I and II of this Policy, the adjudication of
such dispute shall be within the original and exclusive jurisdiction of the Insurance Commissioner, subject to
the limitations provided in Section 416 of the Insurance Code, as amended.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | PRIVATE CAR POLICY (CTPL Only) 5
10. The due observance and fulfillment of the Terms of this Policy, insofar as they relate to anything to be done or
not to be done by the Insured, and the truth of the statements and answer in the proposal, shall be conditions
precedent to any liability of the Company to make any payment under this Policy.

11. In the event that the Company should pay or be held liable to pay any claim or claims under the “No-Fault”
provision of the Insurance Code, the Insured shall reimburse the Company all such sums, whenever the
Insured or his authorized driver or representative has committed a breach of any of the warranties, clauses or
conditions of the Policy, or whenever the circumstances fall under any of the EXCEPTIONS listed in the Policy,
for which the Company would not have been liable were it not for the application of the “No-Fault” provision of
the Insurance Code.

NUCLEAR EXCLUSIONS CLAUSE

1. This Policy does not cover: -

(a) Loss or destruction of, or damage to any property whatsoever or any loss or expense whatsoever resulting
or arising therefrom, or any consequential loss;
(b) Any legal liability of whatsoever nature, directly or indirectly caused by, or contributed to by, or arising from,
ionizing radiations or contamination by radioactivity from any nuclear fuel, or from any nuclear waste from
the combustion of nuclear fuel. For the purpose of this exclusion only combustion shall include any self-
sustaining process of nuclear fission.

2. The indemnity provided by this Policy shall not apply to nor include any loss, destruction, damage or legal
liability directly or indirectly caused by or contributed to, by, or arising from, nuclear weapons material.

CIVIL CODE ARTICLE 1250 WAIVER CLAUSE

IT IS HEREBY DECLARED AND AGREED that the provision of Article 1250 of the Civil Code of the Philippines
(Republic Act No. 386) which reads: -

“In case an extraordinary inflation or deflation of the currency stipulated should supervene, the value of the
currency at the time of the establishment of the obligation shall be the basis of payment...” shall not apply in
determining the extent of liability under the provisions of this Policy.

SHORT PERIOD RATE SCALE

It is hereby agreed, in the event this Policy is surrendered by the Insured for cancellation, the Company shall retain
a premium in accordance with the following scale for the time the Policy has been in force:-

No. of Month/s 1 2 3 4 5 6 7 8 9 10 11
Percentage 20 30 40 50 60 70 75 80 85 90 95

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 policyholder relating
to insurance matters.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | PRIVATE CAR POLICY (CTPL Only) 6
 15th Floor, Sage House, 110 V. A. Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT

POLICY SCHEDULE
authentication no. POLICY NO.
VIRGILIO JR. LANSANG FAJARDO
064ALICD2502 PCOC185743
BLK 3 LOT 9 JAVA ST. CYBERGREENS SUBDIVISION SANTIAGO
GENERAL TRIAS CAVITE BUSINESS / PROFESSION CONFIRMATION OF COVER
4107 0649994988
DATE ISSUED OFFICIAL RECEIPT NO.
JUNE 19, 2025

PERIOD OF INSURANCE
ASSIGNEE INVOICE NUMBER FROM 12:00 NOON TO 12:00 NOON
V0472812 JULY 01, 2025 JULY 01, 2026

SCHEDULE OF VEHICLE
MODEL MAKE TYPE OF BODY COLOR M.V. FILE NO.
TOYOTA WAGON METALLIC GRAY 040100000451750
2017 AVANZA 1.3 E A/T
PLATE NO. serial / chassis no. motor no. authorized capacity unladen weight
DAE9876 MHKM5EF2FHK010058 1NRF300402 7

SECTION I / II THIRD PARTY LIABILITY

Php 200,000.00 Php. 447.01
(SUBJECT TO THE SCHEDULE OF INDEMNITY)

SECTION III (INSURED’S ANNUAL LIMIT OF LIABILITY)

CAR TO CAR COLLISION Not covered Not covered

ACTS OF NATURE Not covered Not covered

deductible authorized TOWING:

REPAIR LIMIT

SECTION IV
1. BODILY INJURY Not covered Not covered

2. PROPERTY DAMAGE Not covered Not covered

AUTO PASSENGER PERSONAL ACCIDENT Not covered Not covered

Forms and endorsement made part of this Policy at the time of issue Total Premium Php. 447.01
waranties and clauses: Documentary Stamps Php. 56.00
Terrorism Exclusion Endorsement Value Added Tax Php. 53.64
Drunk and Drugged Driving Endorsement Local Government Tax Php. 3.35
Sanction Limitation Clause Verification Fee Php. 46.00
Hold Harmless Clause
Php. 606.00
TOTAL AMOUNT DUE

56.00
Documentary stamps to the value of Php ______________ Authorized Signature
has been affixed to the premium register where the policy is recorded.
 15th Floor, Sage House, 110 V. A. Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT

TERRORISM EXCLUSION ENDORSEMENT

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 of 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 similar purpose 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, or 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 Insured 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 Insured.

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

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | MARINE HULL POLICY

 15th Floor, Sage House, 110 V. A. Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT

DRUNK AND DRUGGED DRIVING ENDORSEMENT

Place Issued: Makati City

IT IS HEREBY DECLARED AND AGREED that the Company shall not be liable under any Section of the
Policy in respect of any accident, or liability caused, or incurred by the Insured Vehicle being driven by an
authorized driver who is under the influence of alcohol, dangerous drugs and other intoxicating substances
as defined under the Anti-Drunk and Drugged Driving Act of 2013.

Driving under the influence of alcohol (DUIA) refers to act of operating a motor vehicle while the driver’s Blood
Alcohol Concentration (BAC) level has, after being subjected to an ABA test, reached the level of intoxication,
as established jointly by the DOH, the NAPOLCOM and the DOTC. A driver of a private motor vehicle with a
gross vehicle weight not exceeding 4500kg. having a BAC of 0.05% or higher shall be conclusive proof that
said driver is driving under the influence of alcohol. For drivers of trucks, buses, motorcycles and public utility
vehicles, a BAC of more than 0.0% shall be conclusive proof that said driver is driving under the influence of
alcohol.

Driving under the influence of dangerous drugs and other similar substances (DUID) refers to the act of motor
vehicle while the driver, after being subjected to a refers to the act of operating a motor vehicle while the
driver, after being subjected to a confirmatory test as mandated under Republic Act No. 10586, is found to be
positive for use of any dangerous drug.

Intoxication may be initially assess and determine thru Field Sobriety Tests which refers to standardized tests
namely: the eye test (horizontal gaze nystagmus), the walk and turn and the one-leg stand. Except as varied
by this endorsement, all other terms and conditions of the policy remain the same.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION

By:
Authorized Signature

Conforme:
Insured

Please sign on the space provided for above and return one signed copy to us within thirty (30) days. Your
failure to do so will mean your conformity to this endorsement.
PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | MARINE HULL POLICY
 15th Floor, Sage House, 110 V. A. Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT

SANCTION LIMITATION CLAUSE

The insurer shall not provide cover nor be liable to pay any claim or provide any benefit hereunder to the
extent that the provision of such cover, payment of such claim or provision of such benefit would expose the
insurer or any member of the insurer’s group to any sanction, prohibition or restriction under United Nations
resolutions, Australian autonomous sanctions, or the trade or economic sanctions, laws or regulations of any
country.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | MARINE HULL POLICY

 15th Floor, Sage House, 110 V. A. Rufino Street
Legaspi Village, Makati City 1229, Philippines
Telephone +632 8772 9200 Fax +632 8772 9291
[email protected] www.paramount.com.ph
TIN 000-487-644-000 VAT

HOLD HARMLESS CLAUSE

It is agreed and warranted that in case of sale or transfer of ownership by any instrument of the insured
vehicle described in this policy the Insured Owner / Seller(s) shall:

1. Ensure that the buyer(s) will transfer/register the vehicle in the name of the buyer with the Land
Transportation Office (LTO) by requesting him to do so.

2. Must incorporate in the Deed of Sale or on the instrument transferring ownership a condition that the
buyer shall hold harmless the Insured Owner/Seller from the consequence arising from an accident
involving the vehicle and that the buyer shall fully assume responsibility for such consequences.

3. The Insured Owner/Seller must file with the LTO office where the vehicle was registered a copy of
the Deed of Sale and keep a proof of such filing

Notwithstanding the foregoing, the Insured or the buyer(s) warrant to hold harmless the company from any
liability whatsoever after the sale or transfer of ownership of the insured vehicle.

PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION | MARINE HULL POLICY

 PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION
DIRECT MARKETING
11th Floor, Sage House, 110 V.A. Rufino St.,
Legaspi Village, Makati City, 1229 Philippines
Tel. No.: +632 8539 5200
VAT REG. TIN 000-487-644-00070

BILLING STATEMENT
SERVICE INVOICE
Payor’s Name : VIRGILIO JR. LANSANG FAJARDO Invoice No. : V0472812
Invoice Date : JUNE 19, 2025
Address : BLK 3 LOT 9 JAVA ST. CYBERGREENS Payment Ref. No. : 2600078808

COMPUTER GENERATED DOCUMENT PER BIR ACKNOWLEDGEMENT CERTIFICATE NO. AC_125_032022_000084 | DATE ISSUED: SEPTEMBER 30, 2022
SUBDIVISION SANTIAGO
Policy No. : PCOC185743
GENERAL TRIAS CAVITE
4107 Endorsement No. :
Payor’s TIN : Term of Insurance : JUL 01, 2025 to JUL 01, 2026
SC/ PWD ID : Old Policy No. :
Agent Code : 2756

PARTICULARS
Item Description / Nature of Service Qty. Unit Cost Total Cost
PRIVATE CAR 1 606.00 606.00
UNIT: 2017 TOYOTA AVANZA 1.3 E A/T

PLATE NUMBER: DAE9876

SERIAL NUMBER / CHASSIS: MHKM5EF2FHK010058

MOTOR NUMBER: 1NRF300402

COC NO. 0649994988

Breakdown:

VATABLE SALES ZERO-RATED SALES Premium 447.01

447.01 - Documentary Stamp 56.00
VAT-EXEMPT VAT AMOUNT Local Goverment Tax 3.35

105.35 53.64 Other Fees/ Charges 46.00

VAT Amount 53.64
please make check payment payable to
Total Sales (VAT inclusive) 606.00
PARAMOUNT LIFE & GENERAL INSURANCE CORPORATION
Less: Withholding Tax -
SC/PWD Discount -
TOTAL AMOUNT DUE 606.00

Computer Generated Document

BIR Acknowledgement Certificate No. AC_125_032022_000084 Reynaldo M. Saria
Date Issued: September 20, 2022 Senior Assistant Vice President, Underwriting
Series Range: 0000001 to 9999999 Authorized Representative