PHILIPPINE CROP INSURANCE CORPORATION

Regional Office XI
LIST OF GROWERS
CROP : _____________________
NAME OF LENDER:
NAME OF GROUP :
ADDRESS :

PLANTING EST. DATE VARIETY/ AREA SUM INSURED PREMIUM

NAME OF GROWER FARM LOCATION FIELD No. SIGNATURE OF GROWERS
DATE OF HARVEST CULTIVARS (Hectars) (PHP)

We hereby certify that tha data contained herein are to the best of my knowledge true and
correct and the foregoing farmers are supervised by duly accredited Production Technician. This further
certifies that no risk have occurred up to the inception of cover.
In the event of loss/damage to the crop insured, we hereby assigned any proceeds of
indemnity to the above-named Lending Institution/Lending Conduit.

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Date Name & Signature of Authorized Coop Official