Automobile Insurance Request
Instructions:This form applies to new or renewals of policies so please ensure to fill it out completely especially the mandatory fields (*) . If not applicable, indicate as "n/a" Upon submission, BPI/MS will send you via SMS and E-mail, a quote for the best protection in the market today complete with Acts of God coverage and with easy to follow payment instructions. Please be reminded that by Insurance Commission regulation, a policy is only in effect when full payment has been made.
For policy renewals, please provide your previous year's policy number below.
What type of motor policy would you like to get? *


My Referral Details
Please indicate your bank & branch.
 (e.g. BPI Makati, BFB South-Triangle, others)
Please indicate below the name of your bank person who referred you, if any.
          Employee Name
          Employee ID No.
          Employee Mobile No.
          Employee Email Address

About Myself
Last Name *
First Name *
Middle Name
Date of Birth
Civil Status
T.I.N. *

My Contact Information
Residence Address *
Residence Tel. No./s
Delivery Address *
Note: Type “SAME” if it is no different from the Residence Address.
Mobile No. *
Note: Required as all alerts, confirmation & company updates will be sent via SMS.
Office Address
Office Tel. No./s
Office Fax No./s
Primary Email Address *
Secondary Email Address

My Automobile Information (View List of Prohibited Vehicles)
 Plate No. *
M.V. File No. * Note: The M.V. File No. can be located at the
Note: upper left hand side of the Certificate of
Note: Registration
Serial / Chassis No. *
Engine No. *
Make *
          Others (Please specify)
Model & Submodel *
          Others (Please specify)
Year *
Color *
Vehicle Value *                     PhP

My Dealer Information
Name *
Contact Person *
Telephone No./s *
Fax No./s
Mobile No. *

My Insurance Information
Please indicate start date of cover: *
 Note: Must not be more than 60 days ago.
Accomplished by *
Relationship to Owner
Contact No./s *
For BPI/ BFB Personnel use only:
Please indicate Customer's RM number.
By submitting above information, I signify my intention to insure my property
with BPI/MS Insurance Corporation and that there is no loss as of this day.
For inquiries, you can contact us through, or call us at 840-9000 option 2.
Financial Products of BPI/MS are not insured by the Philippine Deposit Insurance Corporation
and are not guaranteed by the Bank of the Philippine Islands.