PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(GOVERNMENT SERVICE INSURANCE SYSTEM)

Financial Center, Macapagal Boulevard, Pasay City

ACCEPTANCE AND SATISFACTION OF REPAIR

Gentlemen:

Please be advised that undersigned owner and / or duly authorized representative of

hereunder vehicle is fully satisfied and have no further claims or complains with the work done
by _________________________________.

ASSURED :
THIRD PARTY :
UNIT :
PLATE NO :

Thank you,

SIGNATURE OVER PRINTED NAME