Crop-Hail Insurance Application

CROP‑HAIL INSURANCE APPLICATION

Applicant Name:   Tax ID/SSN:

Applicant Contact and Producer

Individual    Partnership    Corporation    LLC    Trust    Other:

Producer / Agent

License No.:   Phone:   Email:

Insured Farm Location / Crop Year

County:   State:   Legal Description:

Crop Year:   Policy Period From:   To:

Crop Schedule and Coverage

Enter an entry for each contiguous field, tract or unit to be insured. Coverage is subject to insurer acceptance and payment of premium.

Coverage Selection and Unit Structure

Coverage Level Selected (% of value per acre):   Deductible:

Unit Structure (check applicable):    Basic Unit    Optional Unit    Enterprise Unit

Payment, Billing and Premium Finance

Premium Due on Binding:   Payment Method (check one or more):    Check    ACH    Credit Card

Declarations, Representations and Certifications

By signing this application the Applicant certifies that all statements and answers contained in this application are true and complete to the best of Applicant's knowledge. Applicant understands that any material misrepresentation or omission may result in denial of coverage or rescission of any policy issued in reliance on this application.

Applicant authorizes inspection of the insured acreage by insurer representatives and agent designees for the purpose of policy underwriting, loss adjustment and verification of planted acreage. Applicant understands that coverage is not effective until accepted and countersigned by the insurer and premium paid as required by insurer rules.

Applicant certifies acreage reported herein is the total acreage owned or operated by the Applicant for the crop year and that no other insurance duplicate coverage exists for the same risk except as disclosed in this application. Applicant agrees to furnish additional documents and proof of production upon request.

Field map or sketch    Seed/planting records    Production history

Privacy and Notices

Applicant acknowledges that insurer may collect and use Applicant's personal and business information for underwriting and claims handling. Applicant authorizes release of information to reinsurers and to parties with a legitimate interest in the administration of this application and any resulting policy. Applicant further understands that this authorization remains in effect for the term of any policy issued.

Applicant Certification (Must be signed)

I certify under penalty of perjury that I have read this application and that the information provided is true and correct. I understand that issuance of any policy is subject to the insurer's underwriting rules and acceptance.

For Internal Use Only

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