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    Aci (Individual) - 2017

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    Psbc Rosario
    1) This document is an application for crop insurance coverage from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, farm details including location, boundaries, crop varieties planted, and requests insurance coverage and premium amounts for crops like rice and corn. 2) The application collects information on 3 farm lots including location, planting dates, land category, soil type, topography, irrigation source and tenure status. 3) The farmer certifies the information provided is true and correct and follows standard agricultural practices, while an agricultural officer also certifies the crops already planted have no insured risks.

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

    Aci (Individual) - 2017

    Uploaded by

    Psbc Rosario
    4K views1 page
    1) This document is an application for crop insurance coverage from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, farm details including location, boundaries, crop varieties planted, and requests insurance coverage and premium amounts for crops like rice and corn. 2) The application collects information on 3 farm lots including location, planting dates, land category, soil type, topography, irrigation source and tenure status. 3) The farmer certifies the information provided is true and correct and follows standard agricultural practices, while an agricultural officer also certifies the crops already planted have no insured risks.

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    pcic form

    Original Title

    ACI ( INDIVIDUAL ) -2017

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    1) This document is an application for crop insurance coverage from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, farm details including location, boundaries, crop varieties planted, and requests insurance coverage and premium amounts for crops like rice and corn. 2) The application collects information on 3 farm lots including location, planting dates, land category, soil type, topography, irrigation source and tenure status. 3) The farmer certifies the information provided is true and correct and follows standard agricultural practices, while an agricultural officer also certifies the crops already planted have no insured risks.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4K views1 page

    Aci (Individual) - 2017

    Uploaded by

    Psbc Rosario
    1) This document is an application for crop insurance coverage from the Philippine Crop Insurance Corporation. It collects basic information about the farmer such as name, address, farm details including location, boundaries, crop varieties planted, and requests insurance coverage and premium amounts for crops like rice and corn. 2) The application collects information on 3 farm lots including location, planting dates, land category, soil type, topography, irrigation source and tenure status. 3) The farmer certifies the information provided is true and correct and follows standard agricultural practices, while an agricultural officer also certifies the crops already planted have no insured risks.

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    RC-UPI-10

    PHILIPPINE CROP INSURANCE CORPORATION 2017/FEB

    Region _____

    APPLICATION FOR CROP INSURANCE


    (Individual Application)
    NEW *RENEWAL
    __________________________________________________________________________________________________________________________________________________________________________________________________
    RICE SELF-FINANCED LENDER ________________________________________ DATE / /
    CORN BORROWING ________________________________________ (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.
    *NOTE: For renewal of coverage, fill-out only the information required in B.3 to B.7. and C.

    I. BASIC INFORMATION
    A. The Farmer

    __________________________________________________________________ _____________________________________________________________________ ________________________________________________________


    Last Name First Name Middle Name

    ___________________________________________________________________________________________________________________________________________________________ _________________________________________
    No. & Street/Sitio Barangay Municipality Province Cell phone Number

    Sex: Male / / Age ___________ Bank Name ____________________________________________________________________________


    Female Date of Birth (mm/dd/yyyy) Bank Account No. _____________________________________________________________________

    Civil Status: Single Married Widow/er Separated Bank Branch / Address ______________________________________________________________
    *If married, Name of Spouse __________________________________________________ ______________________________________________________________
    Name of Legal Beneficiaries: Age Relationship
    (a) Primary _________________________________________________________________________ ___________________________ _____________________________________________________
    (b) Secondary _________________________________________________________________________ ___________________________ _____________________________________________________
    Assignee ____________________________________________________________________________________ Reason for Assignment __________________________________________________________________

    B. The Farm [use separate sheet of application paper if more than three (3) lots]
    Particulars Lot 1 _________ ha. Lot 2 _________ ha. Lot 3 _________ ha.
    B.1. Farm Location/LSP
    Sitio
    Barangay
    Municipality
    Province
    B.2. Boundaries
    North
    South
    East
    West
    B.3. Variety
    B.4. Planting Method1 ( ) DS ( ) TP ( ) DS ( ) TP ( ) DS ( ) TP
    B.5. Date of Sowing
    B.6. Date of Planting
    B.7. Date of Harvest
    B.8. Land Category2 ( ) IR ( ) RF ( ) UL ( ) IR ( ) RF ( ) UL ( ) IR ( ) RF ( ) UL
    B.9. Soil Type3 ( )CL ( )SCL ( )SiL ( )SaL ( )Others ( )CL ( )SCL ( )SiL ( )SaL ( )Others ( )CL ( )SCL ( )SiL ( )SaL ( )Others
    B.10. Topography ( ) Flat ( ) Rolling ( ) Hilly ( ) Flat ( ) Rolling ( ) Hilly ( ) Flat ( ) Rolling ( ) Hilly
    B.11. Source of Irrigation4 ( )NIA/CIS ( )DW ( ) SWIP ( )STW ( )NIA/CIS ( )DW ( ) SWIP ( )STW ( )NIA/CIS ( )DW ( ) SWIP ( )STW
    B.12. Tenurial Status ( )Owner ( ) Lessee ( )Owner ( ) Lessee ( )Owner ( ) Lessee

    C. The Coverage D. For PCIC use:


    Crop: RICE Type of Cover: MULTI-RISK Phase:
    Rice: Wet ___________________ CIC No.: _______________________________________
    CORN NATURAL DISASTER
    Dry ___________________ Date Issued: __________________________________
    Amount of Cover: __________________________ Premium: __________________________________ Corn: A. ___________________ COC No.: ______________________________________
    B. ___________________ Date Issued: __________________________________
    CLTIP – ADSS: Period of Cover: From ____________________
    Sum Insured (SI): __________________________ Premium: __________________________________ To _______________________

    II. CERTIFICATION
    I hereby certify that the above information are true and correct to the best of my knowledge.
    __________________________________________________________
    Signature / Thumb Mark over Printed Name
    Farmer - Applicant
    I hereby certify that the above farmer-applicant follows POT/GAP5, and that, for crop already planted at the time of application, no risk insured against has occurred.

    _____________________________________________________________________
    Date: ___________________________________________ Signature over Printed Name
    Supervising Agricultural Technologist/Account Officer

    Legends:
    1Planting Method: 2Land Category: 3Soil Type: 4Source of Irrigation: 5POT/GAP

    (1) DS – Direct Seeding (1) IR – Irrigated (1) CL – Clay Loam (1) NIA/CIS – National Irrigation Administration/ Package of Technology/
    (2) TP – Transplanting (2) RF – Rainfed (2) SCL – Silty Clay Loam Communal Irrigation System Good Agricultural Practice
    (3) UL – Upland (3) SiL – Silty Loam (2) DW – Deep Well
    (4) SaL – Sandy Loam (3) SWIP – Small Water Impounding Project
    (4) STW – Shallow Tube Well

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