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
DateDate