Underwriting Form No.

2004/01
(Revised 04/2004)

PROPERTY INSURANCE APPLICATION

Name of Assured JUAN DELA CRUZ ELEM SCHOOL

Address POBLACION, JASAAN

MISAMIS ORIENTAL 9003

Date 2 MARCH 2018

GOVERNMENT SERVICE INSURANCE SYSTEM

Cagayan de Oro Branch Office

Attention: Special Business Unit

Gentlemen:

In accordance with Section 5 of Republic Act No. 656, I have the honor to apply for Insurance of the
following property:

1 Property: a. Building 2. Value: a) 1,050,000.00

b. Contents (furniture, fixtures, and equipment) b) 47,650.00

Total 1,097,650.00

3 Location Block No. POBLACION Street

Town/City JASAAN Province MISAMIS ORIENTAL

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) Fire and/or Lightning ü (5) Theft and/or Robbery

(2) Earthquake-Fire & Shock (5) Unauthorized Dismantling
(3) Typhoon (6) Landslide
(4) Flood (7) Others

It 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 the
Inception or from the date of receipt of the bill, whichever is later. As embodied under Section 77,
Insurance Code, "no policy or contract of insurance issued by an insurance company is valid and
binding unless and until the premium has been paid." Therefore, non-payment of the premium
within the prescribed period will cause the GSIS to cancel the policy without prior notice.

I hereby 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 contract between me and the Government Service
Insurance System, Insurance Group.

Done this 2nd day of December 20__,

18 Jasaan, Mis. Or. Philippines.

MARIA LEONORA O. RIVERA

Authorized Signatory

JUAN DELA CRUZ ELEM SCH / PRINCIPAL II

Office / Designation

POBLACION, JASAAN, MISAMIS ORIENTAL / 09051234567

Address / Telephone No.

Note: Please submit Inventory for Office Furniture, Fixtures, Equipment, Machines, Appliances, etc.
 INVENTORY OF PROPERTIES

NAME OF OFFICE: JUAN DELA CRUZ ELEM SCHOOL Date Prepared: 2 MARCH 2018
OFFICE ADDRESS: POBLACION, JASAAN MISAMIS ORIENTAL 9003 9003
Zip Code:________
VALUE OF
DESCRIPTION OF PROPERTY OCCUPANCY OF BUILDING CONTENTS*
(Indicate whether 1-Storey / (Office/ School/ Hospital / VALUE OF BUILDING (Attach Itemized
ITEM 2-Storey, 3-Storey or more) Residential / Commercial) LOCATION OF BUILDING (Sound Value) Inventory per Bldg)
1-STOREY DEP ED STANDARD POBLACION, JASAAN MISAMIS ORIENTAL
Building 1 BUILDING (1 CLASSROOM) SCHOOL 9003 1,000,000.00 16,000.00
1-STOREY BAGONG LIPUNAN I (2 POBLACION, JASAAN MISAMIS ORIENTAL
Building 2 CLASSROOMS) SCHOOL 9003 50,000.00 31,650.00

Building 3

Building 4

Building 5

Building 6

Building 7

Building 8

Building 9

Building 10

*total amount of all Office Furniture, Fixtures, Equipment, Machines, Appliances, etc. TOTAL: 1,050,000.00 47,650.00
which are kept / stowed / used in the corresponding building / property / structure

Prepared By: Certified Correct: Noted:

JANE E. MICABALOS ROY B. BAVIA MARIA LEONORA O. RIVERA

Property Custodian Accountant II Principal II
 Republic of the Philippines
GOVERNMENT SERVICE INSURANCE SYSTEM
Carmen, Cagayan de Oro City

FIRE INSURANCE APPLICATION Date Prepared: 2 MARCH 2018

INVENTORY OF EQUIPMENTS AND MATERIALS

EQUIPMENT/MATERIAL QUANTITY UNIT UNIT VALUE TOTAL VALUE

JUAN DELA CRUZ ELEM SCHOOL
Building 1 - 1-STOREY DEP ED STANDARD BUILDING (1 CLASSROOM)
TABLE 1 piece 3,000.00 3,000.00
CHAIR 40 piece 250.00 10,000.00
ELECTRIC FAN 2 piece 1,500.00 3,000.00
Building 1 Total 16,000.00

Building 2 - 1-STOREY BAGONG LIPUNAN I (2 CLASSROOMS)

Room 1 - Grade 1 Pearl
TABLE 1 piece 3,000.00 3,000.00
CHAIR 35 piece 250.00 8,750.00
ELECTRIC FAN 2 piece 1,200.00 2,400.00
Sub-Total 14,150.00
Room 2 - Grade 2 Acacia
TABLE 1 piece 3,000.00 3,000.00
CHAIR 40 piece 250.00 10,000.00
ELECTRIC FAN 3 piece 1,500.00 4,500.00
Sub-Total 17,500.00
Building 2 Total 31,650.00

GRAND TOTAL 47,650.00

Prepared by: Certified Correct:

JANE E. MICABALOS ROY B. BAVIA
Property Custodian Accountant II