RC-UPI-07

2017/FEB
PAGE 1
PHILIPPINE CROP INSURANCE CORPORATION
Region _____ FOR PCIC ONLY:
CIC No._______________________________ COC No. ___________________________________
APPLICATION FOR CROP INSURANCE Date Issued: ________________________ Date Issued: ______________________________
(Group Application) Crop: ( ) RICE ( ) CORN Period Covered: From: _________________
Phase: To: _____________________
*Name of FO/FA/COOP/IA/Barangay: _________________________________________________________________ Mailing Address: _____________________________________________________________________________ Rice: Wet ______________________ O.R. No. ___________________________________
Dry ________________________ O.R. Date _________________________________
Underwriter / Solicitor: _______________________________________________________________________________ _____________________________________________________________________________ Corn: A. _______________________ Amount Paid ____________________________
B. _______________________
Program: ( ) Regular ( ) SikatSaka ( ) 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 already planted at I hereby certify that the above information are true and correct to the best of my knowledge.
Farmer’s Share (FS) ___________________________
the time of the application, no risk insured against has occurred.
Lending Institution Share (LI) _______________
_________________________________________________ ______________________________ ___________________ Gov’t Premium Subsidy (GPS) _______________
__________________________________________________________ ________________________________________ _________________________
Signature Over Printed Name Office Date Signature Over Printed Name Position Date Gross Premium ______________________________
Less: Underwriter’s/Solicitor’s
LEGENDS: *Type of Group: Incentive (less withholding
FO – Farmers’ Organization COOP – Cooperative tax) ___________________________
FA – Farmers’ Association IA – Irrigators’ Association Net Premium due to PCIC __________________
 APPLICATION FOR CROP INSURANCE

Name of Farmers Adjacent Lot Owners

(Follow the order on page 1) Area *Land **Tenurial
NO. Farm Location (ha.)
Category / Status Signature
Format: First Name Initials, Middle Soil Type
Initial, Full Surname 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