ASSURED INFORMATION
First Name
*
Middle Name/Initial
Surname
*
Birthday
*
Email
*
Contact No.
*
TIN No.
Assured Type
-- Select Type --
Individual
Corporate
House No.
*
Street
*
Province
-- Select Province --
City
-- Select City --
Barangay
-- Select Barangay --
Vehicle and Insurance Details
Year Model
*
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Brand
*
-- Select Brand --
Make
*
-- Select Make --
Engine Series
*
-- Select Engine Series --
Color
*
-- Select Color --
Plate No.
*
Engine No.
*
Serial/Chassis No.
*
Accessories
(Standard Built-In)
Remarks/Note
Insurer
*
Select One...
Mortgagee
Inception
*
Expiry
*
Sum Insured
*
Classification
*
-- Select Classification --
Rate
*
%
Deductible
AON Rate
*
%
Excess Bodily Injury (BI)
*
Property Damage (PD)
*
Seat
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