PHILIPPINE CROP INSURANCE CORPORATION PHILIPPINE CROP INSURANCE CORPORATION

Regional Office No. VII Regional Office No. VII

Name ________________________________ Civil Status _______ Sex _____ Age _____ Name ________________________________ Civil Status _______ Sex _____ Age _____
Address _______________________________ Date of Birth _______________________________ Address _______________________________ Date of Birth _______________________________
Occupation/Livelihood ____________________ Place of Birth ______________________________ Occupation/Livelihood ____________________ Place of Birth ______________________________
Beneficiaries/: Primary ___________________ Relationship ____________________ Age _______ Beneficiaries/: Primary ___________________ Relationship ____________________ Age _______
Secondary __________________ Relationship ____________________ Age _______ Secondary __________________ Relationship ____________________ Age _______
Trustee (if beneficiary is minor) ______________________ Relationship ______________ Age _______ Trustee (if beneficiary is minor) ______________________ Relationship ______________ Age _______
Desired Insurance Coverage : ( ) Plan 15T ( ) Plan 25T ( ) Plan 35T ( ) Plan 45T Desired Insurance Coverage : ( ) Plan 15T ( ) Plan 25T ( ) Plan 35T ( ) Plan 45T
( ) Plan 20T ( ) Plan 30T ( ) Plan 40T ( ) Plan 50T ( ) Plan 20T ( ) Plan 30T ( ) Plan 40T ( ) Plan 50T
For minor applicant only : With my parental consent : For minor applicant only : With my parental consent :
Signature over Printed Name of Parent Signature over Printed Name of Parent

PCIC? (If yes, pls. indicate the name of the farmer and your relationship) Yes _____ No _____ PCIC? (If yes, pls. indicate the name of the farmer and your relationship) Yes _____ No _____
Name of Farmer : ____________________________________ Relationship _______________________ Name of Farmer : ____________________________________ Relationship _______________________
Please answer the following questions: Yes No If yes , give details of diagnosis, duration, Please answer the following questions: Yes No If yes , give details of diagnosis, duration,
1 Have you suffered or sustained any illness names & addresses of Medical Insitutions. 1 Have you suffered or sustained any illness names & addresses of Medical Insitutions.
or injury, consulted a physician or been or injury, consulted a physician or been
hospitalized during the last five (5) years? hospitalized during the last five (5) years?
2 Have you been treated for or told, you have 2 Have you been treated for or told, you have
heart disease, high blood pressure, diabetes, heart disease, high blood pressure, diabetes,
kidney disease, liver disease, urino-genital kidney disease, liver disease, urino-genital
disease , lung disease, cancer, ulcer, or any disease , lung disease, cancer, ulcer, or any
other serious disorders? other serious disorders?
3 Have you ever had or been advised to have 3 Have you ever had or been advised to have
any surgical operations? any surgical operations?
4 Have you ever been declined or had a plan post- 4 Have you ever been declined or had a plan post-
poned or modified for any life or disability ins.? poned or modified for any life or disability ins.?
5 Have you ever been counseled or medically 5 Have you ever been counseled or medically
advised or treated in connection with an HIV advised or treated in connection with an HIV
infection, AIDS or any Sexually Transmitted Disease? infection, AIDS or any Sexually Transmitted Disease?
6 Have you ever travelled to areas with reported 6 Have you ever travelled to areas with reported
cases of SARS (Severe Acute Respiratory Syndrome) cases of SARS (Severe Acute Respiratory Syndrome)
within the past months? within the past months?
7 Have you been diagnosed or tested for SARS? 7 Have you been diagnosed or tested for SARS?
I hereby certify that the foregoing answers & statements are complete, true & correct, signed in I hereby certify that the foregoing answers & statements are complete, true & correct, signed in
person. If the application be approved, the insurance shall be deemed based upon the statements person. If the application be approved, the insurance shall be deemed based upon the statements
contained herein. I further agree that PCIC reserves the right to reject and/or void the insurance if found contained herein. I further agree that PCIC reserves the right to reject and/or void the insurance if found
that there will be fraud,concealment or misrepresentation on this statement material to the risk. that there will be fraud,concealment or misrepresentation on this statement material to the risk.
Signed at ___________________ on this ____ day of __________________, 20__. Signed at ___________________ on this ____ day of __________________, 20__.

Signature of Witness Signature of Applicant Signature of Witness Signature of Applicant