Jose Cojuangco Sons Building

119 Dela Rosa cor C. Palanca Streets, Legaspi Village,

Makati City Philippines
Tel. No. 819-1961 to 66
Fax. No. 819-5217 / 8188639
Email: info@libertyinsurance.com.ph
Website: http://libertyinsurance.com.ph/

ACCIDENT POLICY SCHEDULE

PERSONAL ACCIDENT

Date Issued: July 30, 2018 Policy Number: TPA0026659

Name and Address of Insured: Issuing Office: LIC- Greenhills Service Office
BICOL UNIVERSITY COLLEGE OF ENGINEERING - CIVIL ENGINEERING
DEPARTMENT
LEGAZPI CITY

Total Sum Insured, In Peso Total Premium 17,345.63

50,500,000.00 DST 2,168.20
Prem.Tax 2,081.48
Local Gov't Tax 34.69
TOTAL AMOUNT DUE 21,630.00

Duration: from September 04, 2018 to September 14, 2018 for 11 days.

Itinerary: BICOL-QUEZON CITY-CAVITE-QUEZON CITY-CALAMBA-QUEZON CITY-MANILA-NUEVA ECIJA OR PAMPANGA / PANGASINAN –

QUEZON CITY – BULACAN / CAVITE – LAGUNA / MANILA - LEGASPI

List of Covered Persons:

Name Date of Birth Beneficiary

AGRIPA, JOHN EDGAR M. 09/16/1997 NEAREST KIN
ALAURIN, FRANZ RODIN A. 11/04/1997 NEAREST KIN
ALIANZA, HARCY JAY A. 03/13/1997 NEAREST KIN
ALMONIA, JOHN PATRICK T. 11/15/1998 NEAREST KIN
ARNOZA, MARVIN A. 11/24/1997 NEAREST KIN
ASIADO, RANDY V. 01/29/1997 NEAREST KIN
AZOTEA, JAN RUSSEL 10/11/1996 NEAREST KIN
AZUL, FREDIRICK A. 10/07/1995 NEAREST KIN
BACOLOD, MARK LEANDROW E. 08/22/1997 NEAREST KIN
BAGASALA, CHRISTIAN E. 09/26/1997 NEAREST KIN
BALANA, DANIEL DUANE G. 11/18/1996 NEAREST KIN
BALUTE, JOSEPH V. 07/22/1997 NEAREST KIN
BAÑADERA, BENJO B. 02/10/1996 NEAREST KIN
BAÑARES, KENOSIS DEO N. 09/17/1996 NEAREST KIN
BAROTILLA, JOSAM B. 06/26/1997 NEAREST KIN
BELLO, OSWALD JOHN B. 12/17/1997 NEAREST KIN
BISDA, RYAN VER B. 10/02/1997 NEAREST KIN
BONGON, ORBEL A. 01/30/1998 NEAREST KIN
BONSOL, JOSHUA JOHN S. 09/02/1998 NEAREST KIN
CATANGUI, KARLU ANGELO B. 12/08/1996 NEAREST KIN
CONMIGO, FROILAN O. 02/21/1997 NEAREST KIN
ESCALO, ALJOHN O. 10/12/1997 NEAREST KIN
ESTAYAN, ERROL AL E. 07/11/1998 NEAREST KIN
ESTIPONA, ROI B. 04/28/1997 NEAREST KIN
 Jose Cojuangco Sons Building
119 Dela Rosa cor C. Palanca Streets, Legaspi
Village,
Makati City Philippines
Tel. No. 819-1961 to 66
Fax. No. 819-5217 / 8188639
Email: info@libertyinsurance.com.ph
Website: http://libertyinsurance.com.ph/

Name Date of Birth Beneficiary

FERATERO, NATHANIEL, JR. E. 05/09/1998 NEAREST KIN
FRANCISCO, JOMARI VINCENT B. 05/27/1998 NEAREST KIN
GARING, JC KYRJIE M. 05/14/1991 NEAREST KIN
GATIWAN, CRISTIAN A. 03/18/1997 NEAREST KIN
GONZALES, NATHANNIEL P. 04/03/1997 NEAREST KIN
JAVINES, JOVEN REY N. 10/27/1997 NEAREST KIN
JUMAO-AS, BENJIE B. 02/26/1998 NEAREST KIN
LAGUESMA, DEXTER JOHN L. 10/16/1996 NEAREST KIN
LAWIT, BRYAN JAE L. 09/17/1997 NEAREST KIN
LOBOS, RODRIGO, JR. B. 12/28/1996 NEAREST KIN
LOZARES, GRANT B. 10/01/1997 NEAREST KIN
LUMBERIO, CAMILO JAMA III B. 10/13/1994 NEAREST KIN
MAGDAONG, EMMANUEL S. 09/19/1997 NEAREST KIN
MAGPANTAY, GERSON D. 11/01/1990 NEAREST KIN
MAHINAY, ELIAS JR. A. 06/22/1997 NEAREST KIN
MANGOTARA, MOHAMMAD HAFIZ L. 11/08/1997 NEAREST KIN
MANZANO, FERNAN ERROL S. 11/25/1996 NEAREST KIN
MEULIO, FEB BRUCEWAYNE C. 01/25/1998 NEAREST KIN
MIJARES, KRYSS DEXTER P. 03/07/1997 NEAREST KIN
MIRAFLOR, DAN LESTER M. 02/26/1996 NEAREST KIN
NAVARRO, JETRO L. 07/19/1996 NEAREST KIN
OCAÑA, ADRIAN PAUL 01/10/1998 NEAREST KIN
ORAYE, NOEL, JR. B. 07/20/1997 NEAREST KIN
PELICIA, BRYAN B. 10/13/1995 NEAREST KIN
PRANADA, RAFAEL RANDY S. 10/24/1996 NEAREST KIN
REÑEVO, JOHN REYMARK B. 04/19/1997 NEAREST KIN
SAN MATEO, SYDNEY B. 10/03/1997 NEAREST KIN
SERRANO, BREILLAN C. 01/28/1998 NEAREST KIN
AGUILAR, JUNELA A. 07/14/1997 NEAREST KIN
ANDALIS, NIKKI VANESSA P. 12/10/1997 NEAREST KIN
BADONG, PRECIOUS GIEWEN B. 03/29/1998 NEAREST KIN
BAGUIO, MARJO CHRISTIE R. 07/08/1997 NEAREST KIN
BALDEO, BLESSIE GRACE F. 10/14/1997 NEAREST KIN
BALISTOY, JONELLA JOY B. 12/28/1997 NEAREST KIN
BANUA, CYRILL R. 10/15/1997 NEAREST KIN
BANUA, JOYCE ANNE JEWELMAY A. 06/19/1998 NEAREST KIN
BANZUELA, MARIVIC B. 11/29/1997 NEAREST KIN
BATALLA, JESSA MAY P. 01/27/1998 NEAREST KIN
BENITEZ, JOYCE A. 10/09/1996 NEAREST KIN
BIBON, SHEILA MAE B. 05/08/1997 NEAREST KIN
BITON, MELISSA T. 06/16/1997 NEAREST KIN
BOBIS, MIKKA ELLA S. 08/02/1998 NEAREST KIN
BOLANGA, GRACIELLE B. 03/19/1998 NEAREST KIN
 Jose Cojuangco Sons Building
119 Dela Rosa cor C. Palanca Streets, Legaspi
Village,
Makati City Philippines
Tel. No. 819-1961 to 66
Fax. No. 819-5217 / 8188639
Email: info@libertyinsurance.com.ph
Website: http://libertyinsurance.com.ph/

Name Date of Birth Beneficiary

BOLON, ZHANNIE JANE A. 09/30/1997 NEAREST KIN
BOTICARIO, KRIS CYRELLE L. 08/25/1997 NEAREST KIN
BRUGADA, JANE IRENE P. 12/04/1997 NEAREST KIN
BULAWAN, NEZZIE MARIE K. 03/10/1997 NEAREST KIN
CALLA, AIZA C. 02/08/1997 NEAREST KIN
CORDERO, VHEA ANDREANA M. 10/09/1998 NEAREST KIN
DE ASIS, IVANNE KIM B. 09/01/1998 NEAREST KIN
ENAJE, APRIL KAE B. 02/02/1996 NEAREST KIN
FLORES, ANALIZA B. 09/14/1997 NEAREST KIN
GARGANTA, MA. JIRIS E. 09/18/1996 NEAREST KIN
GELIT, MYKA ANGELA V. 03/01/1997 NEAREST KIN
JARANILLA, DIXZIE MAE D. 05/24/1998 NEAREST KIN
LOMEDA, MIKKY L. 10/30/1997 NEAREST KIN
LOMEDA, NHEKKI L. 07/27/1996 NEAREST KIN
LORIA, TIARA M. 10/15/1997 NEAREST KIN
MARBELLA, TRACY D. 12/13/1997 NEAREST KIN
NUARIN, EMILYN N. 08/24/1998 NEAREST KIN
PACLIBAR, JENELYN A. 12/27/1997 NEAREST KIN
PLOTADO, ROSE ANN D. 08/03/1994 NEAREST KIN
QUINTO, QUEENCY D. 02/14/1998 NEAREST KIN
RICALDE, MAFE L. 02/20/1996 NEAREST KIN
SAYRITAN, WINONA SHANTAL Q. 10/27/1997 NEAREST KIN
VARGAS, PRINCY LEE B. 02/16/1997 NEAREST KIN
YONGCO, MAILA M. 03/24/1997 NEAREST KIN
ENGR. MERCENARIO B. LEGASPI 10/23/1978 NEAREST KIN
ENGR. OLIVER E. ALIGAN 06/29/1960 NEAREST KIN
ENGR. ANALIZA L. GRATIL 11/28/1962 NEAREST KIN
ENGR. JEFFERSON M. CIPRIANO 12/27/1972 NEAREST KIN
VINCENT I. VIRTUCIO 11/26/1957 NEAREST KIN
RYAN E. RAMOS 10/27/1985 NEAREST KIN
JASON NOVORRA 03/10/1991 NEAREST KIN
JOEL A. ARLAN 06/17/1977 NEAREST KIN
CELSO DEATO III 02/21/1979 NEAREST KIN
MA. ELENA M. MARCELINO 09/29/1977 NEAREST KIN
JOHN BENEDICK AYDALLA 01/16/1996 NEAREST KIN
ENGR. DANTE M. GUILLERMO 04/12/1958 NEAREST KIN

Coverage, In Peso
CIVIL CODE ARTICLE 1250 WAIVER CLAUSE:

IT IS HEREBY DECLARED AND AGREED THAT the provision of Articles 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.

IMPORTANT NOTICE

Dear Insured:

We would like to remind all clients that all taxes should be paid immediately upon receipt of the policy. This is in accordance with BIR
Revenue Regulation (RR) Number 9-2000 dated August 31, 2000, BIR Revenue Regulation (RR) Number 15-2001 dated October 16, 2001
and Insurance Commission's Circular Letter Number 7-2002 directed to insurance companies to remit taxes within the month of
issuance.

No refund of documentary stamps on flat or pro rata cancellation will be entertained. Moreover, full payment of documentary stamps is required and
deemed payable for policies issued but not taken up.

For strict compliance.

Thank you for your continous support and understanding

LIBERTY INSURANCE CORPORATION

JOSEFINA M. SALVADOR
President and Chief Operating Officer

AUTHORIZED SIGNATURE

Remarks: