Request for an Insurance Quote

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1. Tel. (02) 922-5555;

2. Tel. (02) 374-8291;

3. Fax. No. 374-8291
Address:
Goldplan Insurance Services

2nd Floor Room 209 The One Executive Office Building
No. 5 West Avenue, Quezon City, Philippines

REQUEST FOR QUOTATION - MOTOR CAR INSURANCE

Department to Contact: *

First Name: *

Last Name: *

E-Mail Address: *

Residence or Business Address *

Landline / Mobile Numbers *

Type of Vehicle(s) *

Brand Name *

Year Model *

Owned or Under Financing *

Fair Market Value

Amount of Previous Insurance Premium

Previous Insurance Company

Comprehensive/TPL *

CAPTCHA Code: *

REQUEST FOR QUOTATION - PERSONAL ACCIDENT INSURANCE

Department to Contact: *

First Name: *

Last Name: *

E-Mail Address: *

Residence or Business Address *

Landline / Mobile Numbers *

Birthday *

Age *

Sex: *

Status: *

Profession or Occupation *

Mode of Transportation: *

Mode of Application: *

If Group, how many individuals?

If applying for Group Personal Accident

Previous Insurance Company

Amount of Previous Insurance Premium

CAPTCHA Code: *

REQUEST FOR QUOTATION - FIRE INSURANCE

Department to Contact: *

First Name: *

Last Name: *

E-Mail Address: *

Residence or Business Address: *

Landline / Mobile Numbers: *

Birthday: *

Age: *

Sex: *

Status: *

Profession or Occupation: *

Description of the Property to be insured: *

No. of Floors: *

No. of Occupants: *

Location Address of the Property: *

Fair Market Value of the Property:

Assesed Market value of the Property:

Property Status: *

Previous Insurance Company

Amount of Previous Insurance Premium

Amount of Insurance Coverage

Available date for Inspection of Property

CAPTCHA Code: *

REQUEST FOR QUOTATION FORM - MARINE INSURANCE

Department to Contact: *

First Name: *

Last Name: *

E-Mail Address: *

Residence or Business Address: *

Landline / Mobile Numbers: *

Type of Vessel: *

Vessel Description: *

Registered Name of Vessel: *

Year Model: *

Fair Market Value: *

Type of Cargo: *

Cargo Description: *

Amount of Cargo: *

Previous Insurance Premium - Vessel:

Previous Insurance Premium - Cargo:

Insurance Coverage - Vessel: *

Insurance Coverage - Cargo: *

CAPTCHA Code: *

RREQUEST FOR QUOTATION FORM -CONTRACTOR'S ALL RISK INSURANCE

Department to Contact: *

First Name: *

Last Name: *

E-Mail Address: *

Residence or Business Address: *

Landline / Mobile Numbers: *

Birthday: *

Age: *

Sex: *

Status: *

Profession or Occupation: *

Description of Project to be insured: *

No. of Floors: *

Average No. of Workers *

Location Address of the Project: *

Project Cost:

Project Timeline

Start Date:

Date of Completion:

Plan (to be submitted): *

Building Plan
Electrical Plan
Safety Plan
Others

Previous Insurance Company:

Amount of Previous Insurance Premium:

Amount of Insurance Coverage:

CAPTCHA Code: *

GUIDELINES ON CLAIMS ASSISTANCE AND PROCESSING OF CLAIMS