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Code Renewal New Business Policy No.

"' .1 ~ ~ ./l:- ~ It ~..~ .1 ~ ~1. ULtJ1u1::n~111J : Insured ftf11~t1~"mtJLnUt11Y1IJI1~LtJ1u1::n~111J..

~tJ Name Location of Property InsuredoJ ,t1iJ'.! Address

D1Ll1tJ ,j"'\1-l~ Ltjg}

Amphoe Changwat Block

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Period of Insurance From at 4.00 p.m. to at 4.00 p.m.

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Total Amount Insured & Description of Property Insured '

D , ~.j~ .1 "'!!I ~600,000.00 U1t1 ~n'imt1a"u"iJnft'i1"Lu~fIln

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Net Premium Baht Stamp Baht Vat Baht Total Baht

5. -;i1~.~L'J~LtJ1tJ1::n~n!JUiI::1J~';-t1U'i::n~ri'!J1.aJ ! Amount of Co-Insurance & Co-Insurers

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This Insurance is subject to the clauses and! or warranties attached

7. -l~ri""qJqJ1U1::n~nlJ -l~ri1MJJti11{jU1::n~ri'1J

Agreement made on Policy issued on

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Agent Insurance Broker License No.

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As evidence the Company has caused this Policy to be signed by duly authorized persons and the Company's stamp to be affixed at its Office.

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n11aJn11" Director M1JJn11 .Director U':f1JJJtJ1JD1~1v .Authorized Signature..

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