Payment Claims Voucher
| Pcv No | 2026-06-032838 | Settle Date | June 09, 2026 |
| Insured Name | UPPER ROOM CITY FELLOWSHIP INTERNATIONAL | Policy No | PA/PPI/C-48752 |
| Claims No | CL/PA/PPI/3975-01 | ||
| No | Invoice No | Description | Exchange Rate | Amount |
|---|---|---|---|---|
| 1 | Payment For: ACCIDENTAL MEDICAL EXPENSE | USD 90.96 | ||
| Pay To: MURILLO SUBRABAS LILY G | ||||
| Payment Status: Full Payment | ||||
| Cheque No: | ||||
| Total | USD 90.96 | |||
| Amount in Word | USD Ninety and Ninety Six Cents Only |
| Reviewed & Appr. PPI | Signature | Name | Date |
|---|---|---|---|
| PREPARED BY | vichet | June 09, 2026 | |
| CHECKED BY AM | KUSORL | June 09, 2026 | |
| VERIFIED BY HOD | SOCHEAN | June 09, 2026 | |
| APPR BY PPI CEO | SALY SOULEVANN | June 09, 2026 |
| Review And Approved By Group : | CHAIRMAN & CEO | CFO |
| Account Code | Account Name | Debit | Credit | |
|---|---|---|---|---|
| 111006 | Claim Paid - PA | 90.96 | ||
| 660020 | Amount due from/(TO)Reinsuranc | 72.77 | ||
| 115506 | Claim Rec.Cam.Re- P.A | 18.19 | ||
| 114006 | Claim Rec.Q.T Share- P.A | 54.58 | ||
| 660216 | ABA - Collection Acct | 90.96 | ||
| TOTAL | 163.73 | 163.73 | ||
Print By: vichet