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D. For PCIC Use

Phase :

CIC No. :

Rice :

Wet :

Date Issued :

Dry :

COC No. :

Corn :

A :

Date Issued :

B :

Period of Cover :

FROM :

TO :

Legends:

1 Planting method :

2 Land Category :

DS- Direct Seeding IR-Irrigated

TP- Transparenting RF- Rainled

UL - Upland

3 Soil Type :

4 Source of Irrigation :

CL - Clay Loarn NIA/CIS - National Irrigation Administration

SCL - Sitty Clay Loarn DW - Deepwell

SL - Sitty Loarn SWIP - Small Water Impounding Project

SAL - Sandy Loarn STW - Shallow Tube Well

II. CERTIFICATION

I Hereby certify that the line above information are true and correct to the best of my knowledge.

Signature/Thumb Mark over Printed Name
Farmer Applicant

I Hereby certify that the above farmer-applicant follows POTIGAPS, and that, for crop already planted at the time of application, no risk insured against has occured.

Signature over Printed Name
Supervising Agricultural Technologist/Account Officer

Date :

Particulars	Farm I.D	Area
B 1 Farm Location/LSP
Sitio
Barangay
Municipality
Province
B 2. Boundaries
North
South
East
West
B 3. Variety
B 4. Planting Method
B 5. Date of Sowing
B 6. Date of Planting
B 7. Date of Harvest
B 8. Land Category
B 9. Soil Types
B 10. Topography
B 11. Source of Irrigations
B 12. Tenurial Status

Republic of the Philippine

Province of Palawan

Municipality of Taytay

Philippine Crop Insurance Corporation

C. The Coverage

Crop : RICE MULTI-TASK

CORN NATURAL DISASTER

Amount of Cover :Premium :

CLTI-ADSS :

Sum Insured (SI) :Premium :

D. For PCIC Use

Phase :

CIC No. :

II. CERTIFICATION