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Property Insurance

GSIS insurance application form for property

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila

PROPERTY APPLICATION FORM
Name of Assured

: _________________________________________ Date: ___________________

Address

: ___________________________________________________________________

GOVERNMENT SERVICE INSURANCE SYSTEM
Financial Center, Roxas Blvd., Pasay City
Attention:

The Manager
Marketing Department
Insurance Group

Sir:
In accordance with Section 5 of Republic Act No. 656, I have the honor to apply for insurance for
the following property:
1. Property:
a. Building
Value
No. of Storeys
Construction Type
b. Contents
(Furniture / fixtures / equipment)
2. Location:
No. _______ Street ___________________________ Town/City _______________________________
Province __________________________________ Block No. ___________ District No. ___________
3. A sketch of the building to be insured and its premises to be drawn at the back hereof.
4. Insurance will be against (please check)
□ Fire/Lightning
□ Typhoon
□ Flood

□ Earthquake/Fire
□ Others (specify)____________________
□ Earthquake/Shock
_________________________________
□ Robbery and Burglary

It is further certified that we shall effect payment of the above-mentioned insurance policies/bills
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, of the Insurance Code, “no policy or 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 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 _____ day of _______________ 20____ in the City of Pasay.
___________________________________
Authorized Signatory
(Signature over printed name)
Office and Designation : ___________________________________
Contact No. : ____________________________________
 
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