OFFICIAL RECEIPT

SI - 1 2 55 08 3
Date: 05-06-2021

Received from
CHG EXPRESS INCORPORATED

BLK 2C LOT 7 JOYOUS HEIGHTS BROOK FIELD ST. SAN JOSE

PERIL COVERAGE PREMIUM
(POB). ANTIPOLO,
OD/Theft 500,000.00 12,350.00
Rizal 1870 AON 500,000.00 1,750.00
TIN : 000-000-000-000 PA 150,000.00 0.00
the sum of **TWENTY THOUSAND FOUR HUNDRED EIGHTY ONE & 98/100** BI 400,000.00 750.00
PD 400,000.00 1,575.00
PREMIUM PAYMENT PHP 20,481.98
Policy Number: SI-CML-500566316
Period: 2021-05-03 to 2022-05-03
Form of Payment: Total Premium : 16,425.00
Premium Tax / E-VAT 1,971.00
Deposit Slip 023/050621/81927
Documentary Stamps 2,053.13
Local Government Tax 32.85
Verification Fee 0.00

External Policy : Sub-Agent Code: CB4TDM COC :

Agent: SI 50001222 AGT MONTES SAMANTHA MURIEL NAVAL
SI 1255083 16-2533-1-SULLANO TOTAL: 20,481.98
NOTICE: The Assured/Intermediary represents and warrants that there is no loss recoverable under the above-numbered policy/ies as of this date. The company accepts payment of the
premium relying on the foregoing representation and/or warranty. In the event that the check payment is covered by this Official Receipt is dishonored, the insurance coverage under
policy shall be invalidated, unless otherwise replaced by a valid payment.
Original Copy
BIR Permit # 1705_0125_PTU_CBA_000102 Date of Issue: May 11, 2017 System Generated. No signature required
SN: SI 000000001 - SI 999999999 Date of Expiry: Valid Until Revoked This document is valid for claim of input tax
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