REPUBLIC OF THE PHILIPPINES GOVERNMENT SERVICE INSURANCE SYSTEM (PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN) COTABATO CITY BRANCH OFFICE Cotabato City PROPERTY INSURANCE APPLICATION Name of Assured Address Date GOVERNMENT INSURANCE SYSTEM Cotabato City Attention: Housing and Insurance Unit Gentlemen: In accor following property ince with Section 5 of Republic Act No. 656, I have the honor to apply for Insurance of the 1. Property: a. Building 2. Value: me 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) Fite and/or Lightning eI (5) Theft and/or Roberry = (2) Earthquake-Fire ist (6) Unauthorized Dismantling ial (3) Earthquake-Shock st (7) Landslide a (4) Typhoon and/or Flood [ea (8) Others. ‘ (= Is 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 ot 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 Thereby 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 “between me and the Government Service Insurance System, Housing and Insurance Unit. Done this day of. ,20___, inthe _ , Philippines. ‘Authorized Signatory NOTE: Please submit Inventory for Office Furnitures, | Fixtures, Machineries, Equipments, etc. Office / Designation ‘Address / Telephone No.