Notice of Cancellation - Mortgagee

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Date

Policy Number :

(Mortgagee)

Sir/Madam:

Notice is hereby given that Motor Car Insurance Policy No. MC-PC-IL-19-0000503-00-D specified
hereunder is canceled due to non-payment of premium:

ASSURED NAME :
ADDRESS :
PROPERTY INSURED :

The policy described above is no longer valid and binding in accordance with Sec. 77 of the
Insurance Code. Any certification of full force, cover note, endorsement is also rescinded.

Very truly yours,

Carlo V. Robles
AVP, Head-Iloilo branch

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