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    AP3 Form No - 01 Application For AP3 and Health Statement

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    Josua arat
    blgi

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    © All Rights Reserved
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    AP3 Form No - 01 Application For AP3 and Health Statement

    Uploaded by

    Josua arat
    42 views1 page
    blgi

    Original Title

    AP3-Form-No_01-Application-for-AP3-and-Health-Statement

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    © © All Rights Reserved

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    blgi

    Copyright:

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

    AP3 Form No - 01 Application For AP3 and Health Statement

    Uploaded by

    Josua arat
    blgi

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    AP3 Form 01

    Rev. 2022/MAY

    Republic of the Philippines


    Department of Finance
    PHILIPPINE CROP INSURANCE CORPORATION
    Regional Office No. ____

    APPLICATION & HEALTH STATEMENT


    AGRICULTURAL PRODUCERS PROTECTION PLAN (AP3)
    Name: ___________________________________________Civil Status _____________Sex ______
    Address : __________________________________________Date of birth ____________Age_______
    Occupation/Livelihood: ______________________________Place of birth______________________
    Beneficiaries/: Primary: ______________________________ Relationship ____________Age______
    Secondary______________________________ Relationship _____________Age______
    Trustee (if beneficiary is a minor) ______________________Relationship _____________Age______
    Desired Insurance Coverage:
    □ Plan 15T □ Plan 40T □ Plan 65T □ Plan 90T
    □ Plan 20T □ Plan 45 T □ Plan 70T □ Plan 95T
    □ Plan 25T □ Plan 50T □ Plan 75T □ Plan 100T
    □ Plan 30T □ Plan 55T □ Plan 80T
    □ Plan 35T □ Plan 60T □ Plan 85T

    For minor applicant only: With my parental consent: ______________________________


    Signature over Printed Name of Parent
    Are you a family member or a worker of a farmer who has a live agricultural/crop insurance coverage
    with PCIC? (If yes, please indicate the name of the farmer and your relationship) Yes _____No______
    Name of Farmer_ _______________________Address: ___________________Relationship ________
    Yes No If yes, give details of diagnosis, duration,
    names and addresses of Medical
    1 Have you suffered or sustained any illness or injury, consulted
    Institutions , name of attending
    a physician or been hospitalized during the last five (5) years?
    physician and medication and
    treatment.
    2 Have you been treated for or told, you have heart disease,
    high blood pressure, diabetes, kidney disease, liver disease,
    urino-genital disease, lung disease, cancer, ulcer, or any other
    serious disorders?

    3 Have you ever had or been advised to have any surgical


    operations?

    4 Have you ever been declined or had a plan postponed or


    modified for any life or disability insurance?

    5 Have you ever been counseled or medically advised or treated


    with any infectious or sexually transmitted disease?

    I hereby certify that the foregoing answers and statements are complete, true and correct, signed in person. If the application be
    approved, the insurance shall be deemed based upon the statements contained herein. I further agree that PCIC reserves the right to
    reject and/or void the insurance if found that there is fraud/ concealment/ misrepresentation on this statement material to the risk.
    Signed at _____________________ on this ______ day of ____________________, 20____.

    _________________________________ _____________________________________
    Name & Signature of Witness Signature of Applicant

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