DESCRIPTION OF VEHICLE/STO BE INSURED PLATE NUMBER (MAKE AND/OR TYPE AMOUNT OF INSURANCE AtrO) aro qrPLandcomeRE []cowpreowy ] Signature oflasured Date Signed EST OULU LAST RAME FIRST NAME. MIDDLE NAME: BIRTHDATE PLACEOF BIRTH GevOER COMPLETE HOME ADDRESS ES. PHONE NO. MOBILENO, EMAIL ADDRESS since [] maprieD [_] ‘WIOOW(ER) NAME AND RELATION TDTHE GIs MEMBER/PENSIONER/ RETIRE applicable) NAMEOF MORTGAGOR (i applicable) qe ASSURED'S EMPLOYER / AGENCY ‘COMPLETE OFFICE ADDRESS PHONENO. PosiiON THLE YEARS INSERVICE GSIS Maaasahan ng Lingkod-Bayan THE GSIS AUTO INSURANCE PROGRAM The GSIS Auto Insurance Program provides full comprehensive coverage inclusive of Acts of Nature for vehicle/s owned, by GSIS members, retirees and their qualified dependents. Who are qualified to apply? - Active GSIS members - GSIS retirees/pensioners = The spouse, children, and siblings of active GSIS members and of GIS retirees/pensioners Parents of active GSIS members What vehicles may be covered? All motor vehicles fpr private use including motorcycles & tricycles provided in good running condition may be covered. What are the requirements? - Completely filled out Auto Insurance application form - Photo copy of the Certificate of Registration (CR) and Official Receipt (OR) - Copy of Bank Financing if the unit is mortgaged ~ Copy of Sales Invoice for brand new vehicles if OR/CR are not yet available ~ Stencil of motor and chassis number for brand new vehicles (if OR/CR are not yet available) - Deed of Sale, ifunit is pre-owned - Fornew applicants for comprehensive insurance cover, coloted photo of the four (4) sides of the vehicle - Incase the applicant for the insurance is not the GSIS member/pensioner, documentary proof of relationship with the GSIS member such as NSO certified copy of Martiage Certificate, Birth Certificate - Photo copy of UMID card for retirees/pensioners What is the mode of payment? Cash and carry NOTE: Approval of application may be subject to vehicle inspection and submission of photo of the vehicle. For inquiries all 976-4900 local 3431 Fax 8590314 www.gsis.govph GSIS Maaasahan ng Lingkod-Bayan