COC No.

: ___________________________
212211017095
Purchase Date: _______________________
2021-11-10
Expiry Date: __________________________
2022-05-11
Please submit this Confirmation of Cover when filing a claim.

CONFIRMATION OF COVER
AHMED ABDULRAHMAN SALEH Ba Elaian
This is to confirm that Mr. /Ms. _______________________________________________ is insured under Vital Cover (COVID-19 Cash
Assistance Benefit+) insurance policy underwritten by Malayan Insurance Co., Inc. with Master Policy No. P0317470 for the following benefits:

BENEFITS LIMITS (PLAN E)

Loss of Life Cash Assistance – death due to Covid-19 Php 12,500.00
Daily Hospital Income Benefit* – due to Covid-19 Php 500.00/day
Loss of Life Cash Assistance – death due to Dengue & Chikungunya Php 12,500.00
Accidental Death Php 12,500.00
Medical Reimbursement - due to accidental injuries only Up to Php 12,500.00
*Up to fourteen (14) days

JOSE PAOLO Y. ABAYA

This confirmation is governed by the terms and conditions of said Master Policy and President and CEO
all claims will be adjusted in accordance therewith. The insurance will commence Malayan Insurance Co., Inc.
12:00 Noon Manila Standard Time the day following date of purchase appearing
above and expiring six (6) months thereafter.

A. Coverages and Benefits

COVID-19 Cash Assistance Benefit +

• Loss of Life Cash Assistance (LLCA) - lump sum benefit following loss of life due to COVID-19 infection.
• Daily Hospital Income Benefit (DHIB) - fixed daily cash benefit for every day of hospital confinement due to COVID-19 (up to a maximum of fourteen [14] days).
• Loss of Life Cash Assistance (LLCA) - lump sum benefit following loss of life due to Dengue or Chikungunya
• Accidental Death (AD) - provides indemnity to the Insured/s for loss of life arising from an accident. The term “accident” for the purpose of this in surance shall be
understood to mean a sudden, unforeseen, violent and external event that result to visible bodily injury or loss of life.
• Medical Reimbursement (MR) - shall mean that the Company will reimburse the actual expense incurred but not to exceed the aggregate amount payable stated in the
Schedule as a result of any one accident, when by reason of injury, the Insured, shall require treatment by a legally qualified physician or surgeon, confinement in a hospital
or the employment of a licensed or graduate nurse.

Terms and Conditions:

COVID-19 Loss of Life Cash Assistance (LLCA) Benefit & DHIB
The contraction of COVID-19 by the Insured must be:
a. medically diagnosed during the policy period or within the Reporting period by (i) a licensed physician or medical professional, (ii) through the use of a nasopharyngeal
swab test kit approved by the Philippine Bureau Food and Drug Administration (BFAD) and/or World Health Organization (WHO) an d (iii) carried out in Department of
Health (DOH) licensed COVID19 hospital or testing center;
b. contracted after fourteen (14) days from effectivity date of policy and within the period of this endorsement; and/or
c. filed and reported to the Company within the Reporting Period (5 days) after expiry of this endorsement

Exclusions specific to COVID-19 Loss of Life Cash Assistance Benefit (LLCA) & DHIB
a. Any accidental injury, sickness or disease other than COVID19;
b. COVID19 infection that is not medically diagnosed by a licensed physician through approved swab test kit and administered in a hospital facility or DOH accredited test
center;
c. COVID19 infection which has been contracted by the insured less than fourteen (14) days from the effectivity of the policy or beyond the Reporting Period.
d. COVID19 illness that had manifested and treated outside the Philippines.
e. Claim for Loss of Life Cash Assistance (LLCA) and or DHIB benefit not supported by medical diagnosis through approved swab te st kit performed by a licensed physician
in a hospital facility or DOH accredited test center.

Loss of Life due to Dengue and Chikungunya Cash Assistance (LLCA) Benefit
Contraction of Dengue or Chikungunya by the insured which was:
a. medically diagnosed by a licensed physician;
b. confirmed through medical procedures administered in a hospital;
c. contracted after fifteen (15) days from effectivity of this endorsement; and
d. contracted beyond a separation period of ninety (90) days between the insured’s most recent clinical diagnosis of Dengue or Chikungunya and the current medical
confirmation of such illness.

Exclusions specific to Dengue and Chikungunya Loss of Life Cash Assistance (LLCA) Benefit
a. Any accidental injury, sickness or disease other than Dengue and Chikungunya;
b. Dengue and Chikungunya fever that is not diagnosed by a licensed physician through tests administered in hospital facilities.
c. Dengue and Chikungunya which has been contracted by the insured within fifteen (15) days from the effectivity of this endorsement
d. Dengue and Chikungunya contracted within the separation period;
e. Claim for Loss of Life Cash Assistance (LLCA) benefit not supported by Dengue and Chikungunya Serology report or medical repo rt issued by a physician.

General Exclusions
The insurance with respect to the above hazards shall not apply to:
1. persons who are under one (1) year old or over seventy-five (75) years old; or mentally impaired or physically handicapped;
2. healthcare workers and nursing professions;
3. loss caused directly or indirectly, wholly or partly by:
 i. bacterial infections, viral infections, sickness or disease (except pyogenic infections which shall occur through an accidental cut or wound); or infections caused by
parasites;
ii. medical or surgical treatment (except such as may be necessary solely by reason of injuries covered by this policy);
iii. miscarriage or pregnancy, any disease of the female reproductive organ;
4. suicide or any attempt thereat whether sane or insane;
5. murder and assault or any attempt thereat;
6. loss occasioned by war, invasion, acts of foreign enemy, hostilities or warlike operations (whether war be declared or not), mutiny, strikes, riots, civil commotion, civil war,
rebellion, revolution, insurrection, conspiracy, sabotage, terrorism, military or usurped power, martial law or state of siege, seizure, quarantine, or customs regulations or
naturalization by or under the order of any government or public or local authority. This exclusion shall not be affected by any endorsement which does not specifically
refer to it, in whole or in part. The application of the exclusion referring to martial law or state of siege is hereby waived for any territorial jurisdiction of the Republic of the
Philippines.
7. nuclear radiation or radioactive contamination;
8. injury sustained while participating in amateur or professional athletics, local sports leagues or international tournaments, or any organized and scheduled amateur physical
contact sport;
9. injury sustained while engaging in but not limited to mountaineering requiring the use of ropes or guides, skin diving employing the use of compressed cylinders, racing on
wheels or horseback, skydiving from device for aerial navigation, hang gliding;
10. cave-in of mines;
11. loss of life or injury sustained as a direct result of, in connection with or attributable to the insured being under the influence of prohibited/regulated drugs or alcohol.
12. loss or damage directly or indirectly caused by, or arising out of the wilful act or negligence of the insured or his rep resentatives
13. loss of life or injury sustained as a direct result of, in connection with or attributable to
i. a commission of a crime or any attempt thereat, iii. avoiding arrest or
ii. violation of rules and regulation on traffic and/or road use; iv. any unlawful act (civil or criminal)

B. Age Eligibility: One (1) to seventy-five (75) years old.

C. Maximum of one (1) Policy per person at any given time. In the event of multiple covers, claim will be lodged on the first i ssued policy and premium for all other effective
applicable policies will be refunded.
D. Hospital confinement includes all Department of Health (DOH) or government designated quarantine, treatment or isolation faci lity manned by health care professionals
who administer medical care and monitoring of COVID-19 infection. Confinement in homes or other accommodation facilities such as but not limited to hotels, resorts,
shelters, etc. without administration of medical care is not covered.

CLAIMS PROCEDURE
IN CASE OF A CLAIM, the Insured or his Dependent/s should submit the following original documents to Malayan Insurance at 500 Q. Paredes St., Binondo, Manila , or at
the nearest Malayan Insurance branch in the Philippines.
Claims Requirements:
General Requirements:
1. Confirmation of Cover (filled-out and signed)
2. Duly accomplished Claims Notification Form
3. Duly notarized Affidavit, Police Report or Incident Report
4. Government issued I.D./Company or School I.D. showing complete home address and signature of Insured, with photo
5. Original or Certified True Copy of Birth certificate of the insured
6. 2 Valid Government I.D.s of Beneficiary with photo and signature
7. Identification of Beneficiary
For Spouse: Marriage Contract
For Parents/Children/Siblings: Birth Certificate
8. Proof of claim payment/quit claim duly signed by the Insured or the Beneficiary
9. All other documents that may be required by the insurer

Additional Requirements for Accidental Death

1. Original or Certified True Copy of Death Certificate issued by the Local Civil Registrar with seal
2. Autopsy Report (as may be required)
3. Photocopy of Medical records

Additional Requirements for Medical Reimbursement (due to accidental injuries only):

1. Medical Certificate from hospital/ attending physician
2. Original Official Receipt
3. Hospital Billing Statement if confined

Additional Requirements for Loss of Life Cash Assistance due to Covid-19 or Dengue and Chikungunya
1. NSO Death Certificate
2. Confirmatory test that the claimant died due to Covid or Dengue and Chikungunya
3. NSO Marriage Certificate (if beneficiary is the spouse)
4. NSO Birth Certificate (if beneficiary is the parent/ child)
5. NSO Birth Certificate of claimant and beneficiary (if beneficiary is sibling)

Additional Requirements for Daily Hospital Income Benefit due to Covid-19

1. Medical Certificate
2. Statement of Account
3. Positive swab test result

NOTICE OF CLAIM
Written notice of injury on which claim may be based must be given to the Company within thirty (30) days after the date of the accident causing such injury. In the event of accidental death,
immediate notice thereof must be given to the Company.
DISCLAIMER
This Confirmation of Cover is intended to be a general summary. For full details on terms, conditions, exclusions and provisions of your coverage, you may request for a copy of the Master
Policy.

PA-B081-1220-0