Insurance Crop Application

INSURANCE CROP APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Partnership Corporation LLC

Tax ID / SSN:     Phone:

Email:     County of Risk:

Policy Details

Multi-Peril Crop Insurance Crop Hail Revenue Protection Actual Production History (APH)

Policy Number (if known):

Coverage Amount per Acre:     Deductible / Coverage Level:     Annual Premium:

Policy Period - Effective From: to

Crop and Acreage Information

Planted Acres:     Insured Acres:     Planting Date:

Expected Yield per Acre:     Unit Price:     Unit of Measure:

Coverage Options and Endorsements

Multi-Peril Coverage
Crop Hail Endorsement
Revenue Protection / RP
Prevented Planting Coverage
Replanting Payment

Exclusions, Limitations, and Acknowledgements

The applicant acknowledges that coverage requested is subject to policy terms, exclusions and limitations. The applicant certifies that the information provided is true and complete to the best of the applicant's knowledge. The insurer's obligations are limited to the terms of any issued policy; excluded perils ordinarily include but are not limited to: wear and tear, inherent vice, deliberate conduct, government seizure, and losses arising from failure to follow accepted agronomic practices.

By initialing, applicant acknowledges reading and understanding key limitations and agrees to permit insurer representatives to inspect records and acreage to verify eligibility and loss. Initials:

Acknowledged Exclusions (check to confirm applicant received and reviewed):
Subrogation and recovery rights
Uninsured perils such as war or nuclear incident
Misrepresentation and fraud consequences

Beneficiary / Payee Information

Primary Payee Name:

Relationship to Applicant:     Percentage Payable:

Payee Tax ID:

Loss Reporting and Documentation

Date of Loss (if reporting now):

Estimated Damage or Loss Amount:

Photographs of damage
Planting receipts / certifications
Sales or storage receipts
Laboratory reports or tests

Declarations and Certifications

The applicant declares that all statements and attachments are accurate, complete, and are representations upon which the insurer may rely in determining insurability and premium. Applicant authorizes the insurer and its representatives to obtain and verify information, including but not limited to production records, planting reports, and third-party loss information, and to perform field inspections as necessary. The applicant acknowledges that false statements, omissions or misrepresentations may result in denial of coverage, rescission of policy, or criminal penalties where applicable.

Applicant agrees that coverage will be governed by the policy terms, endorsements and any applicable statutes or regulations. Premium is due in accordance with the policy and may be billed separately; failure to pay premium when due may result in cancellation or nonrenewal. Any disputes regarding coverage shall be resolved in accordance with the dispute resolution clause set forth in the policy documents.

Fraud Warning: Making false statements or concealing material facts to obtain insurance coverage or payments is insurance fraud and may result in civil and criminal penalties, including denial of claims and rescission of coverage.

I certify under penalty of perjury that the information contained in this application is true and correct and that I am authorized to execute this application on behalf of the named insured.

I have read and agree to the declarations and certifications above.

Attachments Checklist

Please attach and identify the following (check all attached):
Seed and input receipts
Planting report or acreage report
Prior loss history / claims
Field map / GPS boundaries

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