PHILIPPINE CROP INSURANCE CORPORATION

LIVESTOCK INSURANCE
2nd Floor, Bulaylay Marketing Corp. Bldg., National Highway, Tiguma, Pagadian City
Tel. No. (062) 2141737, Fax No. (062) 925-0700
Email Address : philcrop9@yahoo.com.ph

APPLICATION FOR LIVESTOCK MORTALITY INSURANCE

[ ] COMMERCIAL COVER [ ] NON-COMMERCIAL COVER [ ] SPECIAL COVER

NAME OF PROPONENT / APPLICANT : ________________________________________________________________

DATE OF BIRTH : _________________ GENDER : ________ CIVIL STATUS : ________ CONTACT NO: ______________

ADDRESS : ______________________________________________________________________________________

SPOUSE : ________________________________________________ BENEFICIARY : ___________________________

Hereby proposes for insurance coverage of animal/s listed below under the terms and conditions of the General
Provision for PCIC Livestock Mortality Insurance for a period of ___________________________________________
Month/Year from noon of _____________ to noon of __________________ while in the proponent’s farms located
at _______________________________________________________________.

I. Type of Animal/s:
[ ] Cattle [ ] Carabao [ ] Swine [ ] Poultry
[ ] Horse [ ] Goat [ ] Other Specify : _______________________
II. Purpose
[ ] Fattening [ ] Draft [ ] Broilers [ ] Pullets
[ ] Breeding [ ] Milking [ ] Layers [ ] Parent Stock
III. Description of Animals to be Insured
Source of Stock : ____________________________________________________________________
Breed : __________________ Brand : _________________________________________
Ear Mark/Tag : __________________ Basic Color : ___________________________________
No. of Heads/Birds : No. of Housing : ___________________________________
Male : _______________ Age : _____________ No. of Birds per Housing Unit : ________________________
Female : ______________Age : _____________ Date of Purchase : ____________________________
Total Number of Heads for Enrollment : _____________________
For Cattle and Carabao only :
Certificate of Ownership of Large Cattle No. _______________
Certificate of Transfer of Large Cattle No. _________________
IV. Coverage
1. Desired sum Unsured per head : Php ___________________
2. Total Sum Insured : Php ___________________
3. Extended Coverage for Epidemic Diseases :
3.1 _________________________
3.2 _________________________
3.3 _________________________

ASSIGNEE/LOSS PAYEE : ___________________________________________________________________________

Address : _________________________________________________________________________________
Contact No. : _________________________________________________________________________________
Date : _________________________________________________________________________________

___________________________ _________________________________

Name of Livestock Technician Signature