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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Federation of Filipino Chinese

Chamber of Commerce and Industry, Inc. (FFCCCII)

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

LEFT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction

Roof/Others

No. of Storey

External Wall

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P

Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. Bldg

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)LGU building

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Home Economics Building

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. Bldg

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Marcos Pre-Fabricated Sch. Bldg

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Gabaldon Type

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)DepED School Building (Standard)

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type I

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type I

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type I

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Industrial Arts Building

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Magsaysay Type

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)Bagong Lipunan Sch. Bldg Type I

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date

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

I. Applicant/Office
Deped-Catmon Integrated School

Address
San Jose, Catmon, Cebu

Type of Building:
( )RESIDENTIAL

( )COMMERCIAL

( ) INDUSTRIAL

( )OTHERS

( )Office Bldg. (Name) ___________________ ( ) School Bldg. (Name)DepED School Building (Standard)

Contents
Location

Block No.

Lot No.

II. DETAILS OF MATERIALS USED IN THE CONSTRUCTION OF THE BUILDING TO BE INSURED

No. of Storeys
1st Storey
2nd storey
3rd Storey
4th Storey
5th Storey
6th Storey
7th Storey

ROOF/
FLOOR

WALL
FRONT

RIGHT

III. DETAILS OF ADJOINING OR ADJACENT BUILDING ON ALL SIDES

Direction
Roof/Others
No. of Storey
External Wall

LEFT

REAR

DISTANCE FROM BUILDI

Occupied As

TO BE INSURED

FRONT
RIGHT
LEFT
REAR

IV. THERE IS A NIPA HOUSE WITHIN _________________ METERS AWAY FROM BUILDING TO BE INSURED
B. 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 complete
and true to the best of my knowledge and belief and
I agree that this Fire Insurance Applicant shall be the
basis of a contract between me and the GSIS.

_________________________________

I hereby certify that the funds are available

the payment of premiums.

______________________________

Signature

_________________________________
Head Office

Date

Signature

______________________________
Accountant/Treasurer

Date

Contact Number
+639215809138/+639173149394

Value
P
Value
P
Total
P

OCCUPIED AS

DISTANCE FROM BUILDING

TO BE INSURED

a SKETCH

y that the funds are available for

s.

_________________________

Signature

_________________________
countant/Treasurer

Date