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    Application For Crop Insurance

    Uploaded by

    Mark Angelo Ebasco Gofredo
    1. The document is an application for crop insurance covering rice and corn crops. 2. It collects basic information about the farmer such as name, address, farm details, and crop insurance coverage details. 3. The farmer applicant and supervising agricultural technology officer must sign to certify that the information provided is accurate and that no insured risk has occurred for any planted crops.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Application For Crop Insurance

    Uploaded by

    Mark Angelo Ebasco Gofredo
    269 views1 page
    1. The document is an application for crop insurance covering rice and corn crops. 2. It collects basic information about the farmer such as name, address, farm details, and crop insurance coverage details. 3. The farmer applicant and supervising agricultural technology officer must sign to certify that the information provided is accurate and that no insured risk has occurred for any planted crops.

    Original Description:

    brgy san luis

    Original Title

    APPLICATION FOR CROP INSURANCE

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    1. The document is an application for crop insurance covering rice and corn crops. 2. It collects basic information about the farmer such as name, address, farm details, and crop insurance coverage details. 3. The farmer applicant and supervising agricultural technology officer must sign to certify that the information provided is accurate and that no insured risk has occurred for any planted crops.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    269 views1 page

    Application For Crop Insurance

    Uploaded by

    Mark Angelo Ebasco Gofredo
    1. The document is an application for crop insurance covering rice and corn crops. 2. It collects basic information about the farmer such as name, address, farm details, and crop insurance coverage details. 3. The farmer applicant and supervising agricultural technology officer must sign to certify that the information provided is accurate and that no insured risk has occurred for any planted crops.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    APPLICATION FOR CROP INSURANCE

    NEW RICE SELF-FINANCED DATE: _______________


    RENEWAL CORN BORROWING, LENDER: _____________________ (mm/dd/yyyy)

    Sir/Madam:
    I hereby apply for crop insurance coverage under the terms and conditions of the Master Policy Contract and Rules and Regulations of
    the Philippine Crop Insurance Corporation.

    BASIC INFORMATION
    A. FARMER
    Name: ____________________________________________________________________ PCIC ID No.:_________________
    Last Name First Name Middle Name
    Address: ________________________________________________________________________________________________
    No. & Street/Sitio Barangay Municipality Province
    Date of Birth: _________________________________________________ Contact No.:________________________________
    Sex: Civil Status: Indigenous Person:
    Male Single/Unmarried Widow/er Annulled Yes, Tribe: ________________________
    Female Married Legally Separated No
    Spouse: ____________________________________________________________________ PCIC ID No.:_________________

    LEGAL BENEFICIARIES AGE RELATIONSHIP


    Primary ______________________________________________ __________ ____________________________
    Secondary ______________________________________________ __________ ____________________________
    Bank Name ______________
    Assignee: __________________________ Reason of Assignment: __________________ Bank Account No._____________
    Bank Branch/Address___________
    B. FARM
    Area hectare/s REQUIREMENTS:
    Farm Location 1. DULY ACCOMPLISHED APPLICATION FORM
    Sitio ________________________________________ WITH ORIGINAL AT’S SIGNATURE
    Barangay ________________________________________ 2. PHOTOCOPY OF ONE (1) GOVERNMENT
    Municipality ________________________________________ ISSUED ID (WITH DATE OF BIRTH)
    Province ________________________________________ 3. PHOTOCOPY OF RSBSA ENROLLMENT STUB
    4. FARMER APPLICANT’S FILE COPY

    Boundaries BOUNDARIES SHOULD BE PRECISE NAME OF ADJACENT LOT OWNERS


    North ______________________________________________________________________________________
    South ______________________________________________________________________________________
    East ______________________________________________________________________________________
    West ______________________________________________________________________________________
    Variety ____________________________ Land Category IR RF JL
    Planting Method Direct Seeding Transplanting Soil Type CL SCL SIL SaL Other
    Date of Sowing Topography Flat Rolling Hilly
    Date of Planting Source of Irrigation NIA/CIS DW SWIP STW
    Date of Harvest Tenurial Status Owner Lessee

    Land Category Soil Type Source of Irrigation


    IR Irrigated CL Clay Loam NIA/CIS National Irrigation Administration
    RF Rain fed SCL Silty Clay Loam DW Deep Well
    UL Upland SIL Silty Loam SWIP Small Water Impounding Project
    SaL Sandy Loam STW Shallow Tube Well

    C. COVERAGE D. FOR PCIC USE


    Crop RICE Type of Cover MULTI-RISK Phase CIC No.
    CORN NATURAL DISASTER Rice Wet Date Issued ______________
    Amount of Cover Premium ______ Dry COC No. ______________
    CLTI-ADSS Corn A Date Issued ______________
    Sum Insured Premium ______ B Period of Cover ______________

    CERTIFICATION
    I hereby certify that the above information are true and correct to the best of my knowledge.

    Signature/Thumb Mark over Printed Name of Farmer Applicant

    I hereby certify that the above farmer-applicant follows Package of Technology/Good Agricultural Practices, and that, for crop already
    planted at the time of application, no risk insured against has occurred.

    Date: Signature over Printed Name of Supervising Agricultural Technology/Account Officer

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