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MRI: Motor Vehicle
GSIS insurance application form for mortgage redemption of motor vehicle
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republika ng Pilipinas
GOVERNMENT SERVICE INSURANCE SYSTEM
APPLICATION FOR MORTGAGE REDEMPTION INSURANCE
FOR MOTOR VEHICLE LOAN PROGRAM
(please fill up all information in duplicate)
1. Name
Given
Middle
Surname
GSIS Policy No.
2. Date of Birth (mm/dd/yyyy)
4. Office Address:
Tel.#:
3. Place of Birth
5. Home Address
Tel.#:
6. Amount of motor vehicle applied for:
6a. If loan has been approved and fully released, please
indicate so and when.
7. I hereby agree and authorize the Government Service Insurance System or its duly authorized agent to deduct
and collect from my monthly salary the regular monthly premiums and/or additional premiums due on my mortgage
redemption insurance, through my collecting officer, whose concurrence therein appears on Item No.8 hereof, I
further agree to authorize the collecting officer of the office to which I may be subsequently transferred during this
term of my redemption insurance to continue the afrementioned deduction.
8. I concur and agree to collect and remit to the
premiums mentioned in Item. No.7 of this
application upon prior advice from the System.
Signed at
on the
day of
Collecting Officer
right thumbmark
Signature of applicant
Office
Do not fill below this line
M.R.I.R Policy Number
Amount of Insurance
Monthly
Premium:
Date of last monthly:
Premium Due:
Date checked by:
Amount of Approved:
Premium Payment:
Period (years):
