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Philippine Crop Insurance Corporation 1

The document is an application for crop insurance from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, contact details, and bank account information. It also requests information about the farm including location, boundaries, crop variety, planting/harvest dates, land category, soil type, irrigation source, and tenurial status for up to three lots. The farmer certifies that the information provided is true and correct. A supervising agricultural technologist also certifies that the farmer follows recommended practices and that no risks have occurred for the currently planted crop. If approved, the coverage details such as crop insured, type of coverage, amount of coverage, premium, and period of coverage are provided.

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LadyGrace Bonite
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8K views2 pages

Philippine Crop Insurance Corporation 1

The document is an application for crop insurance from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, contact details, and bank account information. It also requests information about the farm including location, boundaries, crop variety, planting/harvest dates, land category, soil type, irrigation source, and tenurial status for up to three lots. The farmer certifies that the information provided is true and correct. A supervising agricultural technologist also certifies that the farmer follows recommended practices and that no risks have occurred for the currently planted crop. If approved, the coverage details such as crop insured, type of coverage, amount of coverage, premium, and period of coverage are provided.

Uploaded by

LadyGrace Bonite
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Insurance Application Form Details
  • Loan and Project Classifications

PHILIPPINE CROP INSURANCE CORPORATION

REGION VIII
APPLICATION FOR CROP INSURANCE
(Individual Application)

NEW RENEWAL Previous Insurance I.D:

RICE SELF-FINANCED DATE:


CORN BORROWING LENDER: (mm/dd/yy)
Sir/Madam,
I hereby apply for crop insurance coverage under the terms and conditions of the Master Policy Contract and Rules and Regulations of the
Philippines Crop Insurance Corporation.

NOTE: for renewal of coverage, Fill-out only the information required in B.3 to B.7 and C.

I. BASIC INFORMATION
A. The farmer
Farmer I.D. IP Tribe:

Last Name First Name Middle Name

No. & Street/Sitio Barangay Municipality Province Cellphone Number


Sex: Male Date of Birth: Bank Name:
Female (mm/dd/yy) Bank Account No:
Civil Status: Single Married Widow/Separated Bank Branch/Address:
If married; Name of Spouse:
NAME OF LEGAL BENEFICIARIES AGE RELATIONSHIP
a. Primary:
b. Secondary:
Assignee: Reason of Assignment;

B. The Farm [use separated sheet of application if more than three (3) lots]
Particulars Lot 1 ha. Lot 2 ha. Lot 3 ha.
B 1. Farm Location/LSP
Sitio
Barangay
Municipality
Province
B 2. Boundaries
North
South
East
West
B 3. Variety
B 4. Planting Methods ( ) DS ( ) TP ( ) DS ( ) TP ( ) DS ( ) TP
B 5. Date of Sowing
B 6. Date of Planting
B 7. Date of Harvest
B 8. Land Category’s ( )IR ( )RF ( )UL ( )IR ( )RF ( )UL ( )IR ( )RF ( )UL
B 9. Soil Type’s ( )CL ( )SCL ( ) SaL ( ) Others ( )CL ( )SCL ( ) SaL ( ) Others ( )CL ( )SCL ( ) SaL ( ) Others
B 10. Topography ( )Flat ( )Rolling ( )Hilly ( )Flat ( )Rolling ( )Hilly ( )Flat ( )Rolling ( )Hilly
B 11. Source of Irrigation ( )NIA/CIS ( )DW ( )SWIP ( )STW ( )NIA/CIS ( )DW ( )SWIP ( ) ( )NIA/CIS ( )DW ( )SWIP ( )
STW STW
B 12. Tenurial Status ( )Owner ( )Lessee ( )Owner ( )Lessee ( )Owner ( )Lessee

C. The Coverage D. For PCIC Use:

Crop: Rice Type of Cover: MULTI-RISK Phase: CIC No:


Corn NATURAL DISASTER Rice: Wet Date Issued:
Dry COC No:
Amount of Cover: Premium: Corn: A Date Issued:

B Period of Cover:
CLTI – ADSS: From:
Sum Insured (SI): Premium: To:

II. CERTIFICATION
I hereby certify that the above information, are true and correct to the best of my knowledge

Signature/Thumbmark over Printed Name


Farmer Applicant
I hereby certify that the above farmer-applicant follows POT/GAP5 and that, for the crop planted at the time of application, no risk against has occurred.

Signature over Printed name


Date: Supervising Agricultural Technologist/Account Officer
Legends:
1. Planting Method 2. Land Category 3. Soil type 4. Source of Irrigation 5. POT/GAP
(1) DS- Direct Seedling (1) IR- Irrigated (1) CL- Clay Loam (1) NIA/CIS- National Irrigation Administration Package of
Technology/
(2) TP- Transplanting (2) RF- Rainfed (2) SCL- Silty Clay Loam (2) DW- Deep well Good Agricultural
(3) UL- upland (3) SiL- Silty Loam (3) SWIP- Small Water Impounding Project Practice
(4) SaL- Sandy Loam (4) STW- Shallow Tube Wall

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