PHILIPPINE CROP INSURANCE CORPORATION

nd
Region VIII 2 floor F. Mendoza Realty Complex 141 Sto, Niño Street Tacloban City

CLAIMS FOR INDEMNITY

(PAGHAHABOL BAYAD)

_______________________
DATE (PETSA)

TO: The Chief CAD

Please send your Team of Adjusters to assess damage of my insured crop
(Mangyaring mapadala kayo ng tagapag-imbistiga upang lasahin and nagging pinsalala ng aking panumin)
Here under are the basic information needed by your office:
(Narito ang mga kinkailangan tala ng inyong tanggapan)

I. BASIC INFORMATION (MGA PANGUNAHING IMPORMASYON):

1. Name of Farmer-assured (Pangalan ng Magsasaka) _______________________________________________
2. Address (Tirahan) ________________________________________________________________________
3. Cell Phone Number (Numbero ng Telephono) ____________________________________________________
4. Location of Farm (Lugar ng Saka) ___________________________________________________________________
5. Insured Crops (Pananim na Ipanaseguro) ( ) Palay ( ) Corn
6. Area Insured (Luwag/Sukal nbg Bukid na Ipinaseguro) ____________________________________ha/s(Hectare
7. Variety Planted (Binhing Innunim): ____________________________________________________________
8. Actual Date of Sowing (Aktwal na Petsa ng Pagsabod): _________________________________________________
9. Actual Date of Planting (Aktwal na Petsa ng Pagtanim): _________________________________________________
10. CIC Number (Numbero ng CIC): ____________________________________________________________________
11. Underwriter/Cooperative (Pangalan ng Ahente o Kooperatiba):_______________________________________
12. Program (Programa): ( ) Regular ( ) Sikat-Saka ( ) RSBSA ( )ACP-CAP-PBD
( ) IIYTA ( ) Yolanda ( ) Iba pa ___________________________

II. DAMAGE INDICATORS (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 (Liwang o Sukta ng Napinsalang Bahagi)______________________________________ ha/s(Hectare
5. Extent/Degree of Damage (Tindi o Porsyento ng pinsala)_________________________________________________
6. Date of Harvest (Petsa ng Pagpapagpas 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)

1. North (Hilaga): ________________________________________

2. South (Timog): ________________________________________
3. East (Silangan): ________________________________________
4. West (Kanluran): ________________________________________

Thank you.

Very truly yours,

___________________________________________________
Signature over Printed Name of Assured Farmer-Claimant
(Lagda sa ibabaw ng Pangalan ng Magsasakang Nakaseguro)