PHILIPPINE CROP INSURANCE CORPORATION RC -UPI-07
Region III 2017/FEB
PAGE 1
APPLICATION FOR CROP INSURANCE FOR PCIC ONLY:
CIC No. ____________________ COC No._____________________
(Group Application) Date Issued:________________ Date Issued:_________________
Crop: ( ) RICE ( ) CORN Period Covered: From: ________
*Name of FO / FA / COOP / IA/ Barangay:__________________________________Mailing Address: ______________________________________ Phase: To:___________
Rice: Wet ______________ O.R. No.:____________________
Underwriter / Solicitor: _________________________________________________ ______________________________________ Dry______________ O.R. Date:___________________
Corn: A. _______________ Amount Paid:________________
B.________________
Program: ( ) Regular ( ) Sikat Saka ( ) RSBSA ( ) APCP-CAP-PBD ( ) PUNLA ( ) Corporate 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:
SEX CIVIL
PLANTING CALENDAR
NAME OF FARMER STATUS
ADDRESS DATE OF CELLPHONE BANK
NAME/ AREA AMOUNT OF
BIRTH NO. (ha.) COVER
NO. SPOUSE BENEFICIARY VARIETY
BANK
(Sitio & Barangay) ACCOUN SOWING / DS PLANTING / TP HARVEST
LAST NAME FIRST NAME MIDDLE NAME Suffix (Sr.,
Jr, etc.) F M S M W (mm/dd/yyyy) T NO
10
11
12
13
14
15
TOTAL
TECHNOLOGIST'S CERTIFICATION CERTIFICATION PREMIUM COMPUTATION(FOR PCIC ONLY)
I hereby certify that the above farmer-applicant follow POT/GAP,and that, for crop I hereby certify that the above information are true and correct to the best of my knowledge. Premium Rate: ___________________________
already planted at the time of the application, no risk insured against has occured.
Farmer's Share (FS) ₱ _____________
_________________________ ________________________ _______________ Lending Institution Share (LI) ₱ ________
Signature Over Printed Name Position Date
Signature Over Printed Name Office Date Gov't Premium Subsidy (GPS) ₱ __________
Gross Premium ₱ _____________________
Less: Underwriter 's / Solicitor's
LEGENDS; * Type of Group: Incentive (less witholding
FO - Farmers' Organization COOP - Cooperative tax) ₱ _____________________
FA - Farmers' Association IA - Irrigators' Association Net Premium due to PCIC ₱ _____________
RC-UPI-07
2017/FEB
PAGE 2
APPLICATION FOR CROP INSURANCE
NAME OF FARMER
ADJACENT LOT OWNERS
( Follow the Order on page 1 ) AREA
*LAND
NO. Format First Name Initials, Middle FARM LOCATION (ha.) CATEGORY / ** Tenurial SIGNATURE
Intial, Full Surname and Suffix Status
SOIL TYPE NORTH SOUTH EAST WEST
ex. J.C.
Dela Cruz Jr
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) Landowner (2) Lessee (3) Others (please specify)
(1) Irrigated - NIA / CIA (A) Broad Plain - Clay Loam
(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
ecify)
