HVCCI UPI Form No.

3
PHILIPPINE CROP INSURANCE CORPORATION
LIST OF GROWERS
CROP __________________

SUMMARY REPORT ON HVCC INSURANCE POLICY NO. H-R0 - ____________________

LENDING INSTITUTION/ASSO/COOP/FA _______________________ 1. Accomplish in 3 copies
ADDRESS: ________________________________________________ 2. Send original and duplicate to PCIC with premiums and
Consolidated Farm Plan and Budget
NUMBER PERIOD OF COVER AREA SUM
NAME OF GROWER FARM DATE OF OF PLANTING/ HARVESTING/ VARIETY / COVERED INSURED TOTAL SIGNATURE OF
LOCATION PLANTING TREES INCEPTION DATE EXPIRY DATE CULTIVARS (ha.) (PhP) PREMIUM CONTACT NUMBER THE GROWER

SUMMARY: TOTAL PREMIUM We hereby certify that the data contained herein are to the best
BASIC PREMIUM (___%) of my knowledge true and correct and that the foregoing farmers are
Doc. Stamps ( ____%) supervised by duly accredited production technician. This further certifies
Premium Tax ( _____%) that no risks has occurred up to the inception cover.
Total Premium Due In the event of loss/damage to crop insured, we hereby assigned any
Date: ______________ proceeds of indemnity to the above-named lender.

Signature Over Printed Name Signature Over Printed Name

Agricultural Production Technician City/Municipal Agriculturist