Correct Insured s Identification Number^ Add or Remove Added County election Change/Correct Insured s Address. Correct SBI s Identification Number^

Transcription

1 APPLCANT S NAME: AGENCY STREET AND/OR MALNG ADDRESS: ADDRESS: CTY: STATE: ZP CODE: APPLCANT S TELEPHONE NUMBER: CELL: DENTFCATON NUMBER: DENTFCATON NUMBER TYPE: AGENCY CODE: CROP POLCY NUMBER: CTY: STATE: ZP CODE: STATE: TELEPHONE: SPOUSE S NAME: PERSON TYPE: TYPE OF POLCY: APPLCANT S AUTHORZED REPRESENTATVE: SPOUSE S DENTFCATON NUMBER: SPOUSE S DENTFCATON NUMBER TYPE: PERSON TYPE: am a limited resource farmer? s applicant insuring the tenant s share? s applicant at least 18 years old? s applicant insuring the landlord s share? OTHER CHANGES: Add or Remove SB NEW APPLCATON TRANSFER RENSTATE ADD CROP TO POLCY CANCELLATON POLCY CHANGES Add/Change/Correct nsured s Authorized Representative Correct nsured s dentification Number^ Correct Spelling of nsured s Name Add or Remove Added County election Change/Correct nsured s Address Correct SB s dentification Number^ Correct Spelling of SB S Name Other (explain in Remarks) SB NFORMATON List all person(s) with a substantial beneficial interest in you as defined in the applicable policy provisions (including landlords or tenants insured under the applicant). f none, state NE. See SSN/EN Reporting From for additional space. NAME COMPLETE ADDRESS PHONE NUMBER DENTFCATON NUMBER & TYPE PERSON TYPE CROP NFORMATON request forshare my share the Category with a designated all added request for my of theofcategory belowbelow with a designated in all in added request for my of theofcategory belowbelow with a designated in all in added withinwithin the state request forshare my share the Category with a designated all added the state f your designated plan of, level of or price is not available in the added, will be proved through the Catastrophic Risk Protection Endorsement, if the crop is insurable in the actuarial documents for an added. f your designated plan of, level of or price is not available in the added, will be proved through the Catastrophic Risk Protection Endorsement, if the crop is insurable in the actuarial documents for an added. EFFECTVE CROP COUNTY NAME OF CROP DESGNATED COUNTY PLAN TYPE COVERAGE LEVEL UNT STRUCTURE (EU OR WF) NEW PRODUCER PRACTCE % OF PRCE, PROJ. PRCE, AMT. OF NS. OR PROT. FACTOR OPTONS, ELECTONS OR ENDORSEMENTS NTENDED REMARKS: Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

2 Policy. CONDTONS OF ACCEPTANCE: This application is accepted and attaches in accordance with the policy unless: (1) The Federal Crop nsurance Corporation determines that, in accordance with the regulations, the risk is excessive; (2) any material fact is omitted, concealed or misrepresented in this application or in submission of this application; (3) you have failed to provide complete and accurate information required by this application; or (4) the answer to any of the following questions is yes. An answer of yes to these questions does not automatically result in rejection of the application. For example, if you answer yes to question (a) but your debt was discharged in bankruptcy; the application would not be rejected. (a) Are you now indebted and the debt is delinquent for under the Federal Crop nsurance Act? (b) Have you in the last five years been convicted under federal or state law of planting, cultivating, growing, producing, harvesting, or storing a controlled substance? (c) Have you ever had under the authority of the Federal Crop nsurance Act terminated for violation of the terms of the contract or regulations, or for failure to pay your delinquent debt? (d) Are you disqualified or debarred under the Federal Crop nsurance Act, the regulations of the Federal Crop nsurance Corporation, or the United States Department of ricultural? (e) Have you ever entered into an agreement with the Federal Crop nsurance Corporation or with the Department of Justice that you would refrain from participating in programs under the authority of the Federal Crop nsurance Act and that agreement is still effective? (f) Do you have like on any of the above crop(s)? understand that if for any crop is currently terminated or would have subsequently terminated for indebtedness had this application been filed after the termination date, no can be provided and am ineligible for any benefits under the Federal Crop nsurance Act until the cause for termination is corrected. We will notify you of rejection by depositing notification in the United States mail, postage paid, to the applicant s address. Unless rejected or the sales closing date has passed at the time you signed this application, shall be in effect for the crop(s) and crop years and shall continue for each succeeding crop year, unless otherwise in the policy, until canceled, terminated or voided. term or condition of the contract shall be waived or changed unless such waiver or change is expressly allowed by the contract and is in writing. CANCELLATON NFORMATON - To be completed only if cancelling without transferring to another Approved nsurance Provider (AP):, hereby request cancellation of my crop policy for the crop(s) and crop year shown on this cancellation. understand that if this form is not executed on or before the cancellation date for any crop year listed, the cancellation of on such crop (s) will not become effective until the following crop year. AP Representative s Printed Name AP Representative s Signature Date POLCY TRANSFER NFORMATON - To be completed only if cancelling previous policy and transferring the experience and from another Approved nsurance Provider (AP):, hereby request cancellation of my crop policy with (Ceding AP Name and Policy Number) for the crop(s) and crop year(s) shown above because have either canceled my crop or applied for with another Approved nsurance Provider. understand that if this form is not executed on or before the established cancellation date for any crop listed, the cancellation of on such crop(s) will not become effective until the following crop year. Crops to be cancelled and transferred: Crop Year of crops being cancelled and transferred:, hereby authorize and direct the shown above to furnish any information relative to my policy to the Assuming Approved nsurance Provider listed below. understand that if for any crop(s) is Ceding Approved nsurance Provider now terminated or would have subsequent terminated for delinquent debt had this transfer not occurred, no can be provided by the Assuming Approved nsurance Provider) Producers nsurance Group, nc. By submission of this form, we agree to provide crop to this applicant for the crop(s) and crop year above unless this form is not executed on or before the established cancellation date for any of the crop(s) shown, in which case will be provided for such crop(s) for the following crop year. Name of Assuming ent Printed Name of AP Representative Authorized to Accept Applications Assuming ent s Address, City, State, and Zip Code Signature of AP Representative Authorized to Accept Applications Date of Acceptance AP Code Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

3 Policy. PRODUCTON REPORT # of Trees / Vines: YELD Yield ndicator: DESC. (ADJ. YELD) Yield Total: # of Trees / Vines: Avg. Yield: App. Yield: Prior Yield: YELD Yield ndicator: New Producer PRODUCTON Record New Producer PRODUCTON Record DESC. (ADJ. YELD) Record New Producer PRODUCTON YELD Yield Total: # of Trees / Vines: Avg. Yield: Avg. Yield: App. Yield: App. Yield: Prior Yield: Prior Yield: Yield ndicator: DESC. (ADJ. YELD) Yield Total: ACREAGE REPORT Acreage nsurability: U nsurability: Measurement Service Requested? U nsurability: Field Location dentification****: Acreage Acreage Field Location dentification ****: U Field Location dentification****: f yes, please provide the unit number(s) and the estimated acreage for which measurement service is requested. Legend: **Percentage Price Election, Projected Price or Amount of nsurance; ***Legal Description = Section, Township, Range, and Other Land dentifier (e.g. Spanish land grants, metes and bounds, etc.); ****Field Location dentification ~Added Land / New Crop / Practice / Type / TMA; C = Claim Record; CRP = Conservation Reserve Program; W = nsurance Waived; NBA = New Breaking Acreage; SR = Short Rate; U - Uninsurable; UR = Unreported ; Acreage Type - dentify whether acreage is: 1 = nsured (planted); 2 = nsured - Acreage emerging from CRP the initial crop year; 3 = nsured - New breaking acreage insured in accordance with the policy the initial crop year; 4 = nsured - New breaking acreage insured in accordance with the policy the initial crop year and the insured in unable to substantiate the acreage has previously been in production; 5 = nsured - New breaking acreage insured by NB WA and the insured is able to substantiate the acreage has previously been in production; 6 = nsured - New breaking acreage insured by NB WA and the insured in unable to substantiate the acreage has previously been in production; 7 = nsured - Native Sod acreage (>5 acres) insured under terms of the policy (subsequent year of planting); 8 = Native Sod (>5 acres) insured under terms of the Special Provisions; 9 = nsured - Native Sod (>5 acres) insured by WA; 10 = nsured - Short Rate acreage; 11 = nsured - Late-planted acreage; 12 = Prevented Planting; 13 = Uninsured; 14 = Uninsurable; 15 = Uninsurable due to 2nd crop provisions; 16 = Uninsurable due to new breaking and insured substantiates the acreage has been in production; 17 = Uninsurable due to new breaking and the insured cannot substantiate the acreage has previously been in production; 18 = Uninsurable - Native Sod acreage (>5 acres) and is not insured by Special Provisions or WA; 19 = Unreported acreage (within the same unit); 20 = Unreported units; 21 = Zero acreage report for unit; 22 = Zero acreage report for ; 23 = neligible SCO Coverage; Record Type Codes: 01 = Prod. Sold / Commercial Storage; 05 = On Farm Storage; 10 = Farm Storage / Record Bin Management; 15 = Livestock Feeding Records; 22 = FSA Loan Record; 25 = Appraisal; 30 = Other; 35 = Pick Records Multi Crop Year Reporting Reason Codes: 1) Certification for crop years not previously certified; 2) Correction; 3) Replacement of a temporary yield; 4) Replacement of assigned yield; 5) Certification by new insured; 6) Certification using another producer s history for new acreage; 7) Recertification for new actuarial offer; 8) Recertification for new unit structure; 9) Other Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

4 Policy. PRODUCTON, REVENUE, AND YELD REPORT Record # of Trees or Vines: PRODUCTON Field Review Required? YELD NET REV. AVG. REV. SHARE Record # of Trees or Vines: New Producer - certify have not produced the insured crop(s) in the for more than two years. 100% REV. New Producer - certify have not produced the insured crop(s) in the for more than two years. nspection Required? DESC. nspection Required? PRODUCTON Total Field Review Required? YELD NET REV. AVG. REV. SHARE 100% REV. DESC. Total Prior Yield Prior Revenue Approved Revenue Prior Yield Prior Revenue Approved Revenue Preliminary Yield Preliminary Revenue Approved Yield Preliminary Yield Preliminary Revenue Approved Yield T-Yield T-Revenue Yield ndicator T-Yield T-Revenue Yield ndicator ACREAGE REPORT Acreage nsurability: Crush District U Frost Protection nsurability: Crush District U Frost Protection Field Location dentification: Measurement Service Requested? Acreage Field Location dentification: f yes, please provide the unit number(s) and the estimated acreage for which measurement service is requested. Legend: **Percentage Price Election, Projected Price or Amount of nsurance; ***Legal Description = Section, Township, Range, and Other Land dentifier (e.g. Spanish land grants, metes and bounds, etc.); ~Added Land / New Crop / Practice / Type / TMA; C = Claim Record; CRP = Conservation Reserve Program; W = nsurance Waived; NBA = New Breaking Acreage; SR = Short Rate; U - Uninsurable; UR = Unreported ; Acreage Type - dentify whether acreage is: 1 = nsured (planted); 2 = nsured - Acreage emerging from CRP the initial crop year; 3 = nsured - New breaking acreage insured in accordance with the policy the initial crop year; 4 = nsured - New breaking acreage insured in accordance with the policy the initial crop year and the insured in unable to substantiate the acreage has previously been in production; 5 = nsured - New breaking acreage insured by NB WA and the insured is able to substantiate the acreage has previously been in production; 6 = nsured - New breaking acreage insured by NB WA and the insured in unable to substantiate the acreage has previously been in production; 7 = nsured - Native Sod acreage (>5 acres) insured under terms of the policy (subsequent year of planting); 8 = Native Sod (>5 acres) insured under terms of the Special Provisions; 9 = nsured - Native Sod (>5 acres) insured by WA; 10 = nsured - Short Rate acreage; 11 = nsured - Late-planted acreage; 12 = Prevented Planting; 13 = Uninsured; 14 = Uninsurable; 15 = Uninsurable due to 2nd crop provisions; 16 = Uninsurable due to new breaking and insured substantiates the acreage has been in production; 17 = Uninsurable due to new breaking and the insured cannot substantiate the acreage has previously been in production; 18 = Uninsurable - Native Sod acreage (>5 acres) and is not insured by Special Provisions or WA; 19 = Unreported acreage (within the same unit); 20 = Unreported units; 21 = Zero acreage report for unit; 22 = Zero acreage report for ; 23 = neligible SCO Coverage; Record Type Codes: 01 = Prod. Sold / Commercial Storage; 05 = On Farm Storage; 10 = Farm Storage / Record Bin Management; 15 = Livestock Feeding Records; 22 = FSA Loan Record; 25 = Appraisal; 30 = Other; 35 = Pick Records Multi Crop Year Reporting Reason Codes: 1) Certification for crop years not previously certified; 2) Correction; 3) Replacement of a temporary yield; 4) Replacement of assigned yield; 5) Certification by new insured; 6) Certification using another producer s history for new acreage; 7) Recertification for new actuarial offer; 8) Recertification for new unit structure; 9) Other Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

5 Policy. PRODUCER S PRE-ACCEPTANCE WORKSHEET LEGAL DESCRPTON* BLOCK OR PLOT # BLOCK OR FARM NAME FSA FARM / TRACT /FELD # MO - PLANTED OR SET OUT VARETY LNE # MO - GRAFTED TYPE TOTAL NUMBER OF PLANTS / TREES / VNES / BUSHES ** PLANT SPACNG DENSTY** PLANTNG PATTERN *** PERCENT OF STAND NTERPLANTED WTH ATHER CROP PRACTCE RR OR N ACREAGE TYPE ROOTSTOCK **** NSURABLE OR UNNSURABLE OR EXCLUDED TOTAL *Legal Description - Section, Township, Range, Other Land dentifier (e.g. Spanish land grants, metes and bounds, etc.; **t applicable to cranberries or lowbush blueberries; ***Planting Pattern - See Exhibit 18 of CH; ****t applicable cranberry, blueberries, and avocado. B = Hedgerow or Border Planting Pattern; D = Double Row Planting; O = Other; Q = Quincunx; H = Hexagonal Planting Pattern; S = Square Planting Pattern Please check or for each question below. Has damage (e.g., disease, hail, freeze) occurred to Trees/Vines/Bushes/Bog that will reduce the insured crop s production from previous crop years? f yes to disease, list type. Have practices or production methods (e.g., removal, dehorning, grafting, transitioning to organic) been performed that will reduce the insured crop s production from previous crop years? A. s acreage transitioning from conventional to organic for the first year? B. s acreage changing from organic to conventional for the first year? Organic: has the acreage been affected by a Prohibited Substance (biological, chemical, or other agent) which results in a change in practice? f yes select: s the current water supply (surface allotment/well) adequate to produce a normal crop for the crop year being certified above? s any of your crop direct marketed or vertically integrated? Organic to Transitional Organic to Conventional REMARKS: Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

6 Policy. NEW PRODUCER New Producer of (List Crop(s) Required): certify have not produced the insured crop(s) in the for more than two years. Field Review Required? nspection Required? NATVE SOD HAVE or HAVE T broken native sod after February 7, understand that if till native sod acreage, will be assessed a reduction in yield guarantee and premium subsidy, these reductions apply in the crop year that my total native sod acreage tilled exceeds 5 acres in the (cumulated across crops and crop years), and these reduction in benefits may be retroactively applied within a crop year. DRECT MARKETNG Will production from any unit be sold by direct marketing? COMMNGLED PRODUCTON Request for Commingled Production The named insured requests that an adjuster measure his production of each unit, because more than one unit will be commingled into the same storage structure. Pro authorizes the insured to use load records along with bin markings due to the large workload and number of claims. The company states that failure to allow this will result in a hardship to the insured. The load records are marketings are identified according to the procedure and production can be identified separately by unit number or field D. TE: Weight tickets must contain the following information: nsured Name. Load or Ticket Number, Crop, Gross Weight, Unit Number, T Area Weight, Date Weighed, Net Weight, Legal Description, D Where Stored, Location of Scale. NTEGRATED / POST-PRODUCTON OPERATONS Am involved in ANY post-production operations including other tax entities? Do Do t n addition of offsets authorized under this provisions of my policy, agree to have unbilled premium and / or administrative fee amounts, which are due to the Company for any policy authorized under the Federal Crop nsurance ( Act ), offset from any indemnity or prevented planting payment due to me for any crop insured with the Company. AUTHORZATON OFFSET FSA / FARM / TRACT / FELD # This item is optional except for the following situations: Acreage insured under written agreement, if required by written agreement as determined by the RMA Regional Office; Acreage emerging from CRP the initial year of planting, all subsequent crop years thereafter; Acreage being planted the initial year of new breaking and all subsequent crop years thereafter; and Units based on FSA Farm Number (with tract / field number optional). ANT-REBATNG CERTFCATON - APPLCANT / NSURED STATEMENT certify, for the crop year indicated, that have not directly or indirectly received, accepted, or been paid, offered, promised, or given any benefit, including money, goods, or services for which payment is usually made, rebate, discount, abatement, credit, or reduction of premium, or any other valuable consideration, as an inducement to procure or in exchange for purchasing this policy after it has been procured. understand that this prohibition does not include payment of administrative fees, performance based discounts, and any other payments approved by FCC that are authorized under sections 508(a)(9)(B) and 508(d)(3) of the Federal Crop nsurance Act (Act) (7 U.S.C. 1508(a)(9)(B) and 1508(d)(3)). understand that a false certification or failure to completely and accurately report any information on this form may subject me, and any person with a substantial beneficial interest in me, to sanctions, including but not limited to, criminal or civil penalties and administrative sanctions in accordance with section 515(h) of the Act (7 U.S.C. 1515(h)) and all other applicable federal statutes. ANT-REBATNG CERTFCATON - AGENT STATEMENT certify, for the crop year indicated, that have neither offered nor promised, directly or indirectly, any benefit, including money, goods, or services for which payment is usually made, rebate, discount, credit, reduction of premium, or any other valuable consideration to this person either as an inducement to procure or in exchange for obtaining after it has been procured. understand that this prohibition does not include payment of administrative fees, performance based discounts, and any other payments approved by FCC that are authorized under sections 508(a)(9)(B) and 508(d)(3) of the Federal Crop nsurance Act (Act) (7 U.S.C. 1508(a)(9)(B) and 1508(d)(3)). understand that a false certification or failure to completely and accurately report any violation may subject me, and all agencies/ companies represent, to sanctions, including but not limited to, criminal or civil penalties and administrative sanctions in accordance with section 515(h) of the Act (7 U.S.C. 1515(h)) and all other applicable federal statutes. Updated: vember 28, 2017 The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits 2018, Pro, All rights reserved.

7 Policy. COLLECTON OF NFORMATON AND DATA (PRVACY ACT) STATEMENT ents, Loss Adjusters and Policyholders The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The Risk Management ency (RMA) is authorized by the Federal Crop nsurance Act (7 U.S.C ) or other Acts, and the regulations promulgated thereunder, to solicit the information requested on documents established by RMA or by approved providers (APs) that have been approved by the Federal Crop nsurance Corporation (FCC) to deliver Federal crop. The information is necessary for APs and RMA to operate the Federal crop program, determine program eligibility, conduct statistical analysis, and ensure program integrity. nformation provided herein may be furnished to other Federal, State, or local agencies, as required or permitted by law, law enforcement agencies, courts or adjudicative bodies, foreign agencies, magistrate, administrative tribunal, AP s contractors and cooperators, Comprehensive nformation Management System (CMS), congressional offices, or entities under contract with RMA. For agents, certain information may also be disclosed to the public to assist interested individuals in locating agents in a particular area. Disclosure of the information requested is voluntary. However, failure to correctly report the requested information may result in the rejection of this document by the AP or RMA in accordance with the Standard Re reement between the AP and FCC, Federal regulations, or RMA-approved procedures and the denial of program eligibility or benefits derived therefrom. Also, failure to provide true and correct information may result in civil suit or criminal prosecution and the assessment of penalties or pursuit of other remedies. NDSCRMNATON STATEMENT n-discrimination Policy: The US. Department of riculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (t all prohibited bases will apply to all programs and/or employment activities.) To File a Program Complaint: f you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to the U.S. Department of riculture, Office of the Assistant Secretary for Civil Rights, 1400 ndependence Avenue, S.W., Washington, D.C , by fax (202) or at program.intake@usda.gov. Persons with Disabilities: ndividuals who are deaf, hard of hearing or have speech disabilities and wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) or (800) (in Spanish). Persons with disabilities, who wish to file a program complaint, please see information above on how to contact the Department by mail directly or by . f you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA's TARGET Center at (202) (voice and TDD). PRODUCERS AG NSURANCE GROUP PRVACY TCE The Producers nsurance Group (Pro Group) is committed to respecting the individual privacy of our policyholders and their significant beneficial interest owners (Customers). We collect nonpublic personal information about Customers from information we receive from them such as information provided on applications or other forms, which may include name, address and social security numbers and from third parties such as a consumer reporting agency. To serve our customers and to service our business our employees have access to Customers personal information in the course of doing their jobs and we may share or disclose non-public personal information about the Customers to affiliates within the Pro Group or with non affiliated third parties with whom we have a contractual relationship such as agencies within the united States Department of riculture, with your agent and other companies or with banks a written permission to transfer such information has been granted by the policyholder. We may also share non-public personal information with affiliates and with non-affiliated third parties as permitted by law. The Pro Group will not sell or share your personal information with anyone for purposes unrelated to our business functions with out our offering to the Customer the opportunity to opt-out or to opt-in as required by law. USDA MULTPLE BENEFT CERTFCATON STATEMENT understand that obtaining multiple Federal benefits for the same loss, such as a ninsured Crop Disaster Assistance Program (NAP) payments(s) and a Federal crop indemnity, is prohibited by law. certify that have, or will disclose any other USDA benefits; including any NAP benefit, received for this crop. Failure to disclose the receipt of multiple Federal benefits, or failure to repay one of the multiple Federal benefits such as either the NAP benefit or the Federal crop indemnity for the same crop, may result in my being disqualified from receiving Federal crop benefits, as well as being ineligible for various programs administered by the Farm Service ency for up to five (5) years. CERTFCATON STATEMENT certify that to the best of my knowledge and belief all of the information on this form is correct. also understand that failure to report completely and accurately may result in sanctions under my policy, including but not limited to voidance of the policy, and in criminal or civil penalties (18 U.S.C and 1014; 7 U.S.C. 1506; 31 U.S.C. 3729, 3730 and any other applicable federal statutes). certify that am responsible for establishing the approved APH yields that are used to calculate the production guarantee contained in this acreage report and that such approved APH yields are correct to the best of my knowledge. Applicant/nsured s Printed Name Updated: vember 28, 2017 Applicant/nsured s Signature Date ent s Printed Name ent s Signature The products offered by Producers nsurance nc. d/b/a Pro may not be a complete list of all products offered and may not be offered in all states. Pro prohibits ent Code Date 2018, Pro, All rights reserved.