REPUBLIC OF THE PHILIPPINES

GOVERNMENT SERVICE INSURANCE SYSTEM

(PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN)
GENERAL SANTOS CITY REGIONAL OFFICE
General Santos City

PROPERTY INSURANCE APPLICATION

Name of Assured

Address

Date

GOVERNMENT INSURANCE SYSTEM

General Santos City

Attention: Housing and Insurance Unit

Gentlemen:

In accordance with Section 5 of Republic Act No. 656, I have the honor to apply for Insurance of the following
property:

1. Property : a. Building 2. Value: a. ₱

b. Contents (furn., fixtures & equipt.) b. ₱

3. Location: No. _______________ Street _____________________ Town or City ____________________________

Province _________________________ Block No. _______________ Dist. No. _____________________

4. A sketch of the building to be insured and its premises to be drawn at the back hereof.
5. Insurance will be against: (Please check)

(1) Fire and/or Lightning (5) Theft and/or Roberry

(2) Earthquake-Fire (6)
(3) Earthquake-Shock (7)
(4) Typhoon and/or Flood (8) Others __________________

It is further certified that we shall effect payment of the above-mentioned insurance policies/bills on a “CASH
and CARRY” basis, or within the prescribed sixty (60) days from inception or from the date of receipt of the bill,
whichever is later. As embodied under Section 77, Insurance Code, “no policy or contract of insurance issued by an
insurance company is valid and binding unless and until the premium thereof has been paid.” Therefore, non-payment of
the premium within the prescribed period will cause the GSIS to cancel the policy without prior notice.

I hereby declare that the above particulars are complete and true to the best of my knowledge and belief, and I
agree that this Property Insurance Application and Certification of Availability of Funds shall be the basis of a contract
between me and the Government Service Insurance System, Housing and Insurance Unit.

Done this _______ day of ___________________, 20____, in the _____________________, Philippines.

Authorized Signatory

NOTE: Please submit Inventory for Office Furnitures,

Fixtures, Machineries, Equipments, etc.
Office / Designation

Address / Telephone No.