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HVCC Insurance Summary Report

This document is a list of growers for crop insurance. It includes fields for listing each grower's name, farm location, date of planting, number of trees, period of insurance coverage, crop variety, insured area and amount, total premium, and signature. It also includes fields to report totals for basic premium, document stamps, premium tax, and total premium due. The certifying officials confirm the data is accurate and no risks have occurred yet. [END SUMMARY]

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Azumi Ayuzawa
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367 views2 pages

HVCC Insurance Summary Report

This document is a list of growers for crop insurance. It includes fields for listing each grower's name, farm location, date of planting, number of trees, period of insurance coverage, crop variety, insured area and amount, total premium, and signature. It also includes fields to report totals for basic premium, document stamps, premium tax, and total premium due. The certifying officials confirm the data is accurate and no risks have occurred yet. [END SUMMARY]

Uploaded by

Azumi Ayuzawa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HVCCI UPI Form No.

3
PHILIPPINE CROP INSURANCE CORPORATION
LIST OF GROWERS
CROP __________________

SUMMARY REPORT ON HVCC INSURANCE POLICY NO. H-R0 - ____________________


LENDING INSTITUTION/ASSO/COOP/FA _______________________ 1. Accomplish in 3 copies
ADDRESS: ________________________________________________ 2. Send original and duplicate to PCIC with premiums and
Consolidated Farm Plan and Budget
NUMBER PERIOD OF COVER AREA SUM
NAME OF GROWER FARM DATE OF OF PLANTING/ HARVESTING/ VARIETY / COVERED INSURED TOTAL SIGNATURE OF
LOCATION PLANTING TREES INCEPTION DATE EXPIRY DATE CULTIVARS (ha.) (PhP) PREMIUM CONTACT NUMBER THE GROWER

SUMMARY: TOTAL PREMIUM We hereby certify that the data contained herein are to the best
BASIC PREMIUM (___%) of my knowledge true and correct and that the foregoing farmers are
Doc. Stamps ( ____%) supervised by duly accredited production technician. This further certifies
Premium Tax ( _____%) that no risks has occurred up to the inception cover.
Total Premium Due In the event of loss/damage to crop insured, we hereby assigned any
Date: ______________ proceeds of indemnity to the above-named lender.

Signature Over Printed Name Signature Over Printed Name


Agricultural Production Technician City/Municipal Agriculturist

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