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RESIDENTIAL FIRE INSURANCE PROPOSAL FORM I. The Proposer Full Name Mailing Address Tel. No. Office Residence Mobile No. Email Address Mortgagee if any II. The Risk Premises Location of Risk Use of Premises Construction of premises a Walls Concrete Brick Concrete Timber Others please specify b Roof Galvanized Iron Sheet c Height One-Storey Two-Storey Others pls. specify Properties Insured Amount of Insurance Building Household contents Cover Required Fire/Lightning Extended Cover Riots Strikes Malicious Damage. Declaration of Proposer Date Signature of Proposer 15/F Citibank Tower. 8741 Paseo de Roxas Makati City 1227 Tel* 848-0188 Fax 752-2200. The Risk Premises Location of Risk Use of Premises Construction of premises a Walls Concrete Brick Concrete Timber Others please specify b Roof Galvanized Iron Sheet c Height One-Storey Two-Storey Others pls. specify Properties Insured Amount of Insurance Building Household contents Cover Required Fire/Lightning Extended Cover Riots Strikes Malicious Damage. specify Properties Insured Amount of Insurance Building Household contents Cover Required Fire/Lightning Extended Cover Riots Strikes Malicious Damage. Declaration of Proposer Date Signature of Proposer 15/F Citibank Tower. 8741 Paseo de Roxas Makati City 1227 Tel* 848-0188 Fax 752-2200. The Risk Premises Location of Risk Use of Premises Construction of premises a Walls Concrete Brick Concrete Timber Others please specify b Roof Galvanized Iron Sheet c Height One-Storey Two-Storey Others pls. specify Properties Insured Amount of Insurance Building Household contents Cover Required Fire/Lightning Extended Cover Riots Strikes Malicious Damage. Declaration of Proposer Date Signature of Proposer 15/F Citibank Tower. 8741 Paseo de Roxas Makati City 1227 Tel* 848-0188 Fax 752-2200.

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