PHILIPPINE CROP INSURANCE CORPORATION

REGION IX
CLAIM FOR INDEMNITY
(PAGHAHABOL BAYAD)
___________________
Date

TO: The Chief CAD

PCIC-RO
Please send your Team of Adjusters to assess damage of my insured crop.
(mangyayaring magpadala kayo ng tagapag-imbistiga upang tahasin ang nagging pinsala ng aking pananim
Hereunder are the basic information needed by your office.
Narito ang mga kinahailanganh tala ng iyong tanggapan:)

I. BASIC INFORMATION (MGA PANGUNAHING IMPORMASYON)

1. Name of Farmer – Assured ( Pangalan ng
Magsasaka)____________________________________________________________
2. Address (Tirahan):
_______________________________________________________________________________________
3. Cell Phone
(NumerongTelepono):____________________________________________________________________________
4. Location of Farm (Lugar ng Saka):
___________________________________________________________________________
5. Insured crops (Pananim na Ipinaedguro): ( ) Palay ( )Corn
6. Area Insured (Luwang/Sukat ng Bukid na Ipinaseguro):____________________________________________ ha. (ektarya)
7. Variety Planted (Binhing Itinanim):___________________________________________________________________________
8. Actual Date of Planting (Aktwal na Petsa ng
Pagkakatanim):_______________________________________________________
9. CIC Number (Numero ng
CIC):______________________________________________________________________________
10. Underwriter/Cooperative (Pangalan ng Ahente o
Kooperatibo):_____________________________________________________
11. Program (Program): ( ) Regular ( ) Sikat Saka ( ) RSBSA ( )APCP-CAP-
PBD
( ) Punla ( ) Cooperative Rice Farming ( ) Others:
____________________

II. DAMAGE INDICATOR (MGA IMPORMASYON TUNGKOL SA PINSALA )

1. Cause of Loss (Sanhi ng
Pinsala):___________________________________________________________________________
2. Date of Loss Occurrence (Petsa ng Pinsala): __________________________________________________________-
________
3. Age/Stage of Cultivation at time of Loss ( Edad ng Pananim ng
Mapinsala)____________________________________________
4. Area Damaged (Luwang o Sukat ng Napinsalang Bahagi ):
_______________________________________________________
5. Extended/Degree of Damage (Tindi o Porsyento ng Pinsala):
_____________________________________________________
 6. Expected Date of Harvest (Tinatayang Petsa ng Pagpapagapas o Pag-ani):
__________________________________________

III. LOCATION SKETCH PLAN OF DAMAGED INSURED CROPS (LSP)

(KROKIS NG BUKID NG MGA NASALANTANG NAKASEGURONG PANANIM)
Isulat ang pangalan ng mga may-ari/nagsasaka ng karatig na sakahan

Lot1 ___ ha. Lot2 ___ ha. Lot3 ___ ha. Lot4 ___ ha.
1. North (Hilaga)
2. South (Timog)
3. East (Silangan)
4. West (Kanluran)

Thank you

Signature over Printed Name of Assured Farmer-Claimant

(Lagda sa ibabaw ng Pangalan ng Magsasakang Nakaseguro)