ORIGINAL COPY

Liberty Insurance Corporation CONFIRMATION OF COVER

NON-LAND TRANSPORTATION OPERATORS
VEHICLE
Jose Cojuangco & Sons Building 119 Dela Rosa cor C. Palanca Streets, Legaspi
Village, Makati City Philippines 046-12345
Tel. No.: 8195217
Email: info@libertyinsurance.com.ph

POLICY NO.
AUTHENTICATION NO.: CV-12345

CONFIRMATION OF
COVER NO.
BUSINESS/PROFESSION
046-12345

DATE ISSUED
NAME AND ADDRESS OF INSURED
04/04/2017 OFFICIAL RECEIPT NO
CANIYAS, BETH MATEO
ADRESS

PERIOD OF INSURANCE

FROM 12:00 NOON TO 12:00 NOON

04/04/2017 04/29/2017

SCHEDULED VEHICLE

MAKE TYPE OF BODY BLT FILE NO.

Ford Zxcv COLOR Asdf123

MODEL/PLATE NO.

1990asdd /
AUTHORIZED
XYZ123 SERIAL/CHASSIS NO. MOTOR NO. UNLADEN WEIGHT
CAPACITY
Asdf Qwerty 55
56

LIMIT OF LIABILITY P 100,000.00

SECTION I/II.
AMOUNTS
THIRD PARTY LIABILITY PREMIUM PAID

(Inclusive of taxes) P 610.00

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

Chapter VI - Compulsory Motor Vehicle Liability Insurance, of the Insurance
Code, as amended by the 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 Coverage.
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 C. PERMANENT
A. DEATH INDEMNITY P 70,000.00 AMOUNT
DISABLEMENT

Burial and funeral expenses 30,000.00

Loss of or Loss of Use

B. BODILY INJURIES AND FRACTURES
of:

Two Limb P 50,000.00

Types of
Accommodation or Maximum Reimbursable Both Hands, or all
Services Rendered 50,000.00
Professional Attendance Fees and/or Charges fingers & both thumbs
Extended

Both Feet 50,000.00

One hand and one foot 50,000.00

Maximum of 45 days per

1. Hospital Rooms P 500.00/day Sight of both eyes 50,000.00
accident

Laboratory examination Injuries resulting in being

2,000.00 50,000.00
fees. X-rays permanently bedridden

Any other injury causing

2. Surgical Expenses Major Operation 7,500.00 permanent total 50,000.00
disablement

Medium Operation 5,000.00 Arm at or above elbow 20,000.00

Arm between elbow and

Minor Operation 1,500.00 15,000.00
wrist

3. Anaesthesiologist's
Major Operation 2,500.00 Hand 15,000.00
Fee

Four fingers and thumb

Medium Operation 2,000.00 15,000.00
of one hand

Minor Operation 500.00 Four Fingers 12,000.00

4. Operating Room Major Operation 1,500.00 Leg at or above the knee 20,000.00

Medium Operation 1,000.00 Leg elbow knee 15,000.00

Minor Operation 500.00 One foot 15,000.00

All toes of one foot 10,000.00

For daily visits of

5. Medical Expenses 400.00/day Thumb 8,000.00
practitioner or specialists

Index Finger 6,000.00

The total amount of

medical expenses must
5,000.00 Sight of one eye 20,000.00
not exceed (For a single
period of confinement)

2-2 Hearing-both Ears 30,000.00

4/4/2017 12:40:08 PM
 Hearing-one Ear 15,000.00

Actual value of drugs IMPORTANT NOTICE

6. Drugs and Medicines and medicines used but 20,000.00 The Insurance Commissioner, with offices in Manila,
not to exceed 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
Actual amount charged insurance companies. He is ready at all times to
7. Ambulance for ambulance transport 1,500.00 render assistance in settling any controversy
but not to exceed between an insurance company and a policyholder
relating to insurance matters.

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