PHILIPPINE CROP INSURANCE CORPORATION

Regional Office No._____

LOCATION SKETCH PLAN (LSP)
NAME OF COOPERATIVE/FO/FA: CROP : ____________________
MAILING ADDRESS:

FARM INFORMATION
No. NAME OF FARMER FARM LOCATION AREA Land NAME OF ADJACENT LOT OWNERS/CULTIVATORS OR LANDMARKS
Sitio/Barangay/Town INSURED Class* NORTH (IBABA) EAST (SILANGAN) WEST (KANLURAN) SOUTH (ILAYA)
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We, the farmers whose names and signatures appear above, hereby certify to the correctness of the foregoing information. We
further certify that we are under the supervision of an Agricultural Technologist and that we observe the DA-recommended
technology in our Municipal / City.

FOR PCIC USE ONLY Prepared by: Attested by:

Phase:

Printed Name and Signature Printed Name and Signature

INSTRUCTION: Agricultural Technician Municipal/ City Agriculturist
Borrowing Farmers (GCIS) - Pls. accomplish 3 copies. Date: ______________________________ Date: ______________________
Self-Financed Farmers (GCIS) - Pls. accomplish 2 copies.