CAS-02

PHILIPPINE CROP INSURANCE CORPORATION

2017/FEB
Region III-A

CLAIM FOR INDEMNITY

(PAGHAHABOL BAYAD)
_________________________
DATE (PETSA)
TO : The Chief CAD
PCIC-RO

Please send your Team of Adjusters to assess damage of my insured crop.

(Mangyaring magpadala kayo ng tagapag-imbistiga upang tasahin ang naging pinsala ng aking pananim
Hereunder are the basic information needed by your office:
Narito ang mga kinakailangang tala ng iyong tanggapan:)

I. BASIC INFORMATION (MGA PANGUNAHING IMPORMASYON):

1. Name of Farmer-Assured (Pangalan ng Magsasaka): _____________________________________________________________________

2. Address (Tirahan): ___________________________________________________________________________________________________________
3. Cell Phone Number (Numero ng Telepono): ________________________________________________________________________________
4. Location of Farm (Lugar ng Saka): __________________________________________________________________________________________
5. Insured Crops (Pananim na Ipinaseguro): ( ) Palay ( ) Corn
6. Area Insured (Luwang/Sukat ng Bukid na Ipinaseguro): _________________________ ha. (ektarya)
7. Variety Planted (Binhing Itinanim): _______________________________________________________________
8. Petsa ng Pamumunla: ________________________________ _Aktuwal na Petsa ng Pagtatanim_________________________________
9. CIC Number (Numero ng CIC): ___________________________________________________________________
10. Underwriter/Cooperative (Pangalan ng Ahente o Kooperatiba): _________________________________________________________
11. Program (Programa): ( ) Regular ( ) Sikat Saka ( ) RSBSA ( ) APCP-CAP-PBD
( ) Punla ( ) Cooperate Rice Farming ( ) Others: _______________________________

II. DAMAGE INDICATORS (MGA IMPORMASYON TUNGKOL SA PINSALA)

1. Cause of Loss (Sanhi ng Pinsala): _______________________________________________________________
2. Date of Loss Occurrence (Petsa ng Pinsala): ___________________________________________________
3. Age/Stage of Cultivation at time of loss (Edad ng Pananim ng Mapinsala): ______________________________________________
4. Area Damaged (Luwang o Sukat ng Napinsalang Bahagi): ____________________ ha. (ektarya)
5. Extent/Degree of Damage (Tindi o Porsyento ng Pinsala): ____ ______________ % (porsyento)
6. Expected Date of Harvest (Tinatayang Petsa ng Pagpapagapas o Pag-ani): _____________________________________________

III. LOCATION SKETCH PLAN OF DAMAGED INSURED CROPS (LSP)

(KROKIS NG BUKID NG MGA NASALANTANG NAKASEGURONG PANANIM)
Isulat ang pangalan ng mga may-ari/nagsasaka ng karatig na sakaha

Lot 1 ____ ha. Lot 2 ____ ha. Lot 3 ____ ha. Lot 4 ____ ha.

1. North (Hilaga) _____________________ _____________________ _____________________ _____________________

2. South (Timog) _____________________ _____________________ _____________________ _____________________
3. East (Silangan) _____________________ _____________________ _____________________ _____________________
4. West (Kanluran) _____________________ _____________________ _____________________ _____________________

IV. COST OF PRODUCTION INPUTS AT THE TIME OF LOSS (HALAGA NG MGA GINASTOS NANG MAPINSALA)
1. Land preparation (Upa sa paggagayak ng bukid) Php ______________________
2. Cost of pulling of seedlings/transplanting (Upa sa bunot at tanim) ______________________
3. Cost of seeds (Halaga ng binhi) ______________________
4. Cost of fertilizer (Halaga ng abono) ______________________
5. Cost of chemicals (Halaga ng kemikal) ______________________
6. Others (Iba pa.) ______________________

TOTAL _______________________

Thank you.

Very truly yours,

_______________________________________________________________________
Signature over Printed Name of Assured Farmer-Claimant
(Lagda sa ibabaw ng Pangalan ng Magsasakang Nakaseguro)
Note: Accomplish in 3 copies(Gawin ng 3 kopya)