FIP Form No.

01
Rev. 2011/Dec

PHILIPPINE CROP INSURANCE CORPORATION

Regional Office No.______

APPLICATION FOR FISHERIES INSURANCE

Date:______________
Sir/Madam:

I hereby apply for Aquaculture Insurance Coverage under the terms and conditions of
the Master Policy Contract and pertinent rules and regulations of the Philippine Crop Insurance
Corporation.

I. BASIC INFORMATION
A. Name of Fisherfolk/Grower
B. Address
C. Name of Spouse
D. IP Tribe
II. FARM DESCRIPTION
A. Type of Aquaculture Farm
B. Environment of Aquaculture Farm
C. Location
D. Number of Units
E. Lot Numbers
F. Size of Units
III. INSURANCE INFORMATION
A. Name of Fisherfolk/Group
B. Source of Financing
C. Desired Amount of Cover
D. Premium Due
E. Date of Stocking
F. Date of Harvest
G. Stock Size Number
H. Stocking Density
I. Stock Survival Rate
K. Source of Stocks
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Name: ____________________________________
Address: ____________________________________

Attachments: 1. Aquaculture Insurance Farm Plan and Budget

2. Location Sketch Map/Control Map
3. Certified photo copy of Permit to Operate issued by BFAR/NIA

Processed by: ______________________ Reviewed by:_______________________

CAIC Number:_______________________