Tr s chnh ti TP H Ch Minh Ta nh Kumho Asiana Plaza, tng 15 39 L Dun, Qun 1 TP H Ch Minh, Vit Nam T: (84-8) 38 125 125 Fax:

(84-8) 38 125 018

Chi nhnh ti H Ni Lu 16, Ta nh Quc t Ha Bnh 106 Hong Quc Vit, Q.Cu Giy H Ni, Vit Nam T: (84-4) 37 557 111 Fax: (84-4) 37 557 066

BNG PH
LIBERTY INSURANCE LIMITED NGI C BO HIM A CH

MR CHUNG
THNG TIN CHUNG

: Bo Xung, Thu Duc, Ho Chi Minh

S CMND/H CHIU M S KHCH HNG LOI HNH BO HIM TRUNG GIAN BO HIM GII HN A L : 0 : Bo him Xe t : NGUYN TRNG BO-00029368 : VIETNAM : : S MY S KHUNG T HOT NG KINH DOANH M S THU

: : : NGY PHT HNH:

HP NG BO HIM S

P-MPB-005361-13
NM SN XUT S CH NGI DUNG TCH NG C : : : :

29/01/2013 2006 7 3597 28/01/2014 23:59

MC MIN THNG

XE C BO HI

HIU & S LOI XE BIN KIM SOT S THI HN BO HIM

AUDI-Q7.3.6
: BOXUNG : BOXUNG :

MC CH S DNG : Khng KD

29/01/2013

00:00

N PH BO HIM

PHM VI BO HIM VT CHT XE

S TIN BO HIM

Tng S tin Bo him

PHN I

VND

1,730,000,000 C bo him C bo him C bo him Khng bo him VND 32,687,246.

1. VND 1,000,000 mi v tn tht; 30% gi tr mi v tn tht do Thy kch

Tn tht ton b Tn tht b phn Mt cp ton b Mt cp b phn

TRCH NHIM I VI BN TH BA

Trch nhim dn s bt buc ca ch xe t

PHM VI BO HIM C YU CU
PHN II

Mc trch nhim bo him mi ngi mi v (cho ngi th ba v hnh khch VND theo hp ng vn chuyn) Mc trch nhim bo him mi v (cho ti sn ca ngi th ba) Thng tt thn th (mi ngi/v) VND VND VND

KHNG P DNG

Phn Trch nhim t nguyn

Thit hi ti sn (mi v) Tng cng (mi v)

KHNG P DNG

TAI NN I VI NGI NGI TRN XE

PHN III

T vong hoc Thng tt vnh vin (bao gm 10% chi ph y t)

DCH V H TR

KHNG P DNG

PHN GIA TNG

Xe thay th dng tm ch sa cha H tr cu h Trong sut thi hn bo him VND 4,000,000. VND VND VND VND VND . 32,687,246. 4,903,087. 2,778,416. 30,562,575.

TNG PH BO HIM BN TNH PH NY C TH THAY I M KHNG CN BO TRC GIM PH I DIN CNG TY (Thay mt Cng ty Bo him) (Ch k Ngi c thm quyn & Ngy k) THU GI TR GIA TNG TNG S TIN THANH TON QUY TC BO HIM:

THEO HP NG BO HIM T CA CNG TY BO HIM LIBERTY (phin bn UW-MLT-W-001-11-V ) V (CC) IU KHON B SUNG SAU:

1. Khng bo him cho xe taxi, xe cho thu t li v xe chy tuyn c nh 2. Qu khch s c sa cha v thay th ph tng ti Garage do qu khch la chn

I DIN NGI C BO HIM (Thay mt Ngi c Bo Him)

M S NGI S DNG PH TRCH KHCH HNG NGY IN:

(Ch k & Ngy k) 29/01/2013