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No. 7504 Bagtikan St., San Antonio Village, Makati City Billing Statement # : BS-0068319 PRINTED
Billing Statement Date : 05/16/19
Tel No.: (632) 810-1653 to 60 Fax No.:(632) 814-8098
Policy Order # : PO-0092361
Amount Due : 4,539.93
Due Date : 05/08/19

Insurance Details

Billing Address : RM 403 NATIONAL LIFE INSURANCE BLDG., 6762 AYALA AVE., Policy/Endorsement No. : SI-PCP-500076109

Insurer Tin : 000-821-466-000-___-

Client : DICUANGCO, LUCIANO P. Insurer Ref. # :

Inception Date : 04/08/19

Expiry Date : 04/08/20
Client Code : 2676
Type Of Coverage : MOTOR
Client Tin : 1077154161
Contact Person : CONCORDIA R. LUNGAY
Item Insured : UTA-449 | 1997 MITSUBISHI LANCER 4DR -
Contact No. : 243-01-81 to 88 COMPREHENSIVE

Fax No. : 242-21-62 Client Terms : 30 DAYS

Email : Trans Type : RENEW
Remarks : UTA-449 | 1997 MITSUBISHI LANCER 4DR -

Premium Summary
Description Premium Amount Charge Amount Total Amount
ACTS OF NATURE 504.00 0.00 504.00
BODY INJURY 420.00 0.00 420.00
PROPERTY DAMAGE 1,245.00 0.00 1,245.00
OWN DAMAGE / THEFT 1,471.68 0.00 1,471.68
LGT 0.00 7.28 7.28
EVAT 0.00 436.88 436.88
Documentary Stamp 0.00 455.09 455.09
3,640.68 899.25 4,539.93

Payment Schedule
30 DAYS PAYMENT SCHEDULE (w/ 100% of stamps & taxes payable in their first installment) Due Date Amount Due
05/08/19 4,539.93

Important Notes:
1. Sec. 77 of the Insurance Code states that “an insurer is entitled to payment of the premium as soon as the thing insured is exposed to the peril
insured with. Notwithstanding any agreement to the contrary, no policy or contract of insurance issued by an insurance company is valid and
binding unless and until premium thereof has been paid....”
2. Once policy is issued, the Documentary Stamp Tax will be chargeable to you. Your insurer will no longer refund or will collect from you whether
this policy is subsequently cancelled or paid.
3. Sec. 315 of the Insurance Code states that the premium collected by the insurance broker from the insured “which is to be paid to an insurance
company because of the assumption of liability through the issuance of policies and contracts of insurance shall be held by the broker in a
fiduciary capacity.” As your broker we are authorized to collect on behalf of the insurer.
4. Under the VAT regulations, the insured gets the input tax from the insurer and under the expanded withholding tax regulation; any creditable
withholding tax certificate on taxes withheld by the Insured must be issued in the name of the Insurer.

Please attach BIR form 2307 Certificate in the name of Insurer for payment net of withholding tax.
Otherwise the amount deducted and withheld shall remain outstanding and demandable for payment.

Please make your check payable to TRINITY INSURANCE BROKERS, INC

For changes in contact details, please indicate so on the space provided for below:

For queries or concerns, please call our trunk line numbers (632) 810-1653 or email us at Our office is at the No. 7504 Bagtikan St., San Antonio
Village, Makati City Makati City Philippines ,. You may also visit our website


Note: This is a systems-generated and approved billing statement. No signature required. Page 1 of 1