S IS coverpment service insurance system G TatGnat fins, raparan, Cousyon Cty aban S508 PROPERTY INSURANCE APPLICATION (Fire Insurance) Name of Assured/Applicant Address Date Gentlemen: Im accordance with Section 5 of Republic Act No. 656, I have the honor to apply for Insurance of the following property: L.Property: a. Building 2.Value: a. Php Name of Building being insured: Please specify and check: 1-2Storey Class A ~ Made of concrete w/o any element of light materials 3-4 Storey. Class B ~ All other types of construction except light materials 5-8 Storey Class C~ Light Materials i) Mortgaged: (Yes / No) b.Contents (Furnitures, Fixtures & Office Equipment) a. Php (IT, Communication, Scientific, Medical Equip & Cameras) —_b. Php. (Heavy/Construction, Generator Set, Scientific Equipment). Php. (Others: . Php 3, Location: No. Street Town or City Province, Block No. Dist.No. 4. Sketch of the building to be insured and its premises to be drawn at the back hereof. 5, Insurance will be against: (Please check) ‘Type of Insurance: (Plese check) Fire and/or Lightning Typhoon aNew __ b.Full Earthquake 4. Flood b. Renewal I is further certified that we shall effect payment of the above-mentioned insurance policies/bills on a “CASH- AND-CARRY” basis, or within the prescribed sixty (60) days from inception or from the date of receipt of the bill, ‘whichever is later. As embodied under Section 77, Insurance Code, “no policy or contract of insurance issued by an insurance company is valid and binding unless and until the premium thereof has been paid.” Therefore, non-payment of the premium within the prescribed period will cause the GSIS to cancel the policy without prior notice. Thereby declare that the above particulars are complete and true to the best of my knowledge and belief, and 1 agree that this Property Insurance Application and Certification of Availability of Funds shall be the basis of a contract between me and the Government Service Insurance System, Insurance Group. Done this___day of __20__,in the. Philippines. NOTE: To avoid inconvenience in paying/disapproval of future claim, please complete the following requirements: ‘Authorized Signatory 1) Dulyfiled out Application orm 2) atest Inventory with Latest Appraised Value 3) Pletures ofthe property (4 sides front back & sides) 2) Building lan/Site Development Pan, 5). Viiniey Map or Location Map, a 6) Cost of Building Material/Renovaion Office /Designation For Office Building Contents: 1) Latest Inventory with ts year purchased & netbook value - ‘Address/Telephone No.