FOR PCIC ONLY:
CIC No. _________________________ COC No. ______________________________
PHILIPPINE CROP INSURANCE CORPORATION Date Issued: ____________________ Date Issued: ______________________________
Region 13 Crop: ( ) RICE ( ) CORN Period Covered: From: _________________
Phase: To: _____________________
Rice: Wet ______________________ O.R. No. ___________________________________
APPLICATION FOR CROP INSURANCE
Dry ______________________ O.R. Date _________________________________
(Group Application) Corn: A. ______________________ Amount Paid ____________________________
B. ______________________
*Name of FO/FA/COOP/IA/Barangay: ____________________________________________________________ Mailing Address: _____________________________________________________________________
Underwriter / Solicitor: __________________________________________________________________________ _________________________________________________________________________
Program: ( ) Regular ( ) Sikat Saka ( ) RSBSA ( ) APCP-CAP-PBD ( ) PUNLA ( ) Cooperate Rice Farming ( ) Others: ___________________
We, bonafide members/residents of the above FO/FA/Cooperative/IA/Barangay, whose names and signatures appear herein and on page 2, hereby apply for crop insurance and certify to the correctness of the information shown here
below and on page 2:
Name of Farmers Gender
Civil
Date of Birth Bank Name / Amount of Planting Calendar
NO. (F/M)
Status Address (Sitio & Barangay) (mm/dd/yy) Cellphone No. Spouse Beneficiary Variety
Last Name First Name Middle Name
Suffix (S/M/W) Bank Account No. Cover Sowing/DS TP/Planting Harvest
(Sr., Jr. etc.)
10
11
12
13
14
15
TOTAL
TECHNOLOGIST'S CERTIFICATION CERTIFICATION PREMIUM COMPUTATION (FOR PCIC ONLY):
Premium Rate: _________________________________
I hereby certify that the above farmer-applicants follow POT/GAP, and that, for crop I hereby certify that the above information are true and correct to the best of my knowledge.
Farmer’s Share (FS) ___________________________
already planted at the time of the application, no risk insured against has occurred.
Lending Institution Share (LI) _______________
GERTRULYN T. NATONTON MUN. AGRICULTURIST ___________________ Gov’t Premium Subsidy (GPS) _______________
_ NICA N. GABALES MAO - BTA
Signature Over Printed Name Position Date Gross Premium ______________________________
Signature Over Printed Name Office ____________________
Date
Less: Underwriter’s/Solicitor’s
Incentive (less withholding
LEGENDS: *Type of Group: tax) ___________________________
FO – Farmers’ Organization COOP – Cooperative Net Premium due to PCIC __________________
FA – Farmers’ Association IA – Irrigators’ Association
APPLICATION FOR CROP INSURANCE
Name of Farmers
(Follow the order on page 1) *Land Adjacent Lot Owners
Area Category **Tenurial
NO. Format: First Name Initials, Farm Location (ha.) / Soil Status Signature
Middle Initial, Full Surname Type
and Suffix North South East West
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
TOTAL
*LAND CATEGORY / SOIL TYPE: **TENURIAL STATUS:
LEGENDS For Rice Crop (Land Category): For Corn Crop (Soil Type/ Topography):
(1) Irrigated – NIA/CIA (A) Broad Plain – Clay Loam (1) Landowner (2) Lessee (3) Others (please specify)
(2) Irrigated – Deep Well Pump / Shallow Tube Well (STW) (B) Broad Plain – Silty Clay Loam
(3) Irrigated – Open Source (SWIP, Creek, River) (C) Broad Plain – Silty Loam
(4) Rainfed (D) Broad Plain – Sandy Loam
(E) Rolling/Upland
