GSIS based on KSBPM GSIS : Generic Statistical Information System.
GSIS Fire Insurance.xlsx
60
GSIS FORM No. L-680-3-012 (revised 5/84) GOVERNMENT SERVICE INSURANCE SYSTEM FIRE INSURANCE APPLICATION (To be written in Triplicate) Thru GSIS Cebu City Branch Type of Building: Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OT P Contents Value P Location Block No. Lot No. Total P II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED ROOF/ WALL OC FLOOR FRONT RIGHT LEFT REAR 1st Storey 2nd storey 3rd Storey 4th Storey 5th Storey 6th Storey 7th Storey III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES DISTANCE FROM Direction Roof/Others No. of Storey External Wall Occupied As TO BE INS FRONT RIGHT LEFT REAR IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSU B. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Oth of the Location of the Building proposed for coverage. I hereby declare that the above particulars are comp I hereby certify that the funds a and true to the best of my knowledge and belief and the payment of premiums. I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS. _________________________________ _____________________ I. Applicant/Office Deped-Catmon Integrated School Address San Jose, Catmon, Cebu Contact Nu +63921580913 Filipino Chinese Chamber of Commerce and Industry, Inc. (FFCCCII) No. of Storeys IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of
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Transcript of GSIS Fire Insurance.xlsx
BLDG15GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Federation of Filipino Chinese Chamber of Commerce and Industry, Inc. (FFCCCII)ContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG14GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. BldgContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG13GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)LGU buildingContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG12GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Home Economics BuildingContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG11GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. BldgContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG10GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. BldgContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG9GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Gabaldon TypeContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG8GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)DepED School Building (Standard)ContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG7GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type IContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG6GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type IContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG5GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type IContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG4GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Industrial Arts BuildingContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG3GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Magsaysay TypeContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG1GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type IContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
DateDate
BLDG2GSIS FORM No. L-680-3-012 (revised 5/84)GOVERNMENT SERVICE INSURANCE SYSTEMFIRE INSURANCE APPLICATION(To be written in Triplicate)
Thru GSIS Cebu City BranchI. Applicant/Office Deped-Catmon Integrated SchoolAddress San Jose, Catmon, CebuContact Number +639215809138/+639173149394
Type of Building:Value ( )RESIDENTIAL ( )COMMERCIAL ( ) INDUSTRIAL ( )OTHERSP( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)DepED School Building (Standard)ContentsValuePLocationBlock No.Lot No.TotalPII. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSUREDNo. of StoreysROOF/WALLOCCUPIED ASFLOORFRONTRIGHTLEFTREAR1st Storey2nd storey3rd Storey4th Storey5th Storey6th Storey7th StoreyIII. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDESDISTANCE FROM BUILDINGDirection Roof/OthersNo. of StoreyExternal WallOccupied As TO BE INSUREDFRONTRIGHTLEFTREARIV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSUREDB. RISKS INSURED AGAINST: ( Please Check Preferences) ( ) Fire and Lightning ( ) EarthQuake-Fire ( ) Typhoon And/Or Flood
( ) Earthquake-Shock ( ) Unauthorized Dismantling ( ) Others(Specify)IMPORTANT: Attach INVENTORY of Office Furniture/Fixtures/Equipments/Etc. At the back of this form, draw a SKETCH of the Location of the Building proposed for coverage.
I hereby declare that the above particulars are completeI hereby certify that the funds are available forand true to the best of my knowledge and belief and the payment of premiums.I agree that this Fire Insurance Applicant shall be the basis of a contract between me and the GSIS.
_________________________________ _________________________________SignatureSignature
_________________________________ _________________________________Head OfficeAccountant/Treasurer
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