Policy Transfer/Application for Multiple Peril Crop Insurance

Policy Transfer/Application

With Supplemental Coverage Endorsement
Multiple Peril Crop Insurance

Identification Number (Tax ID):

Type of Identification Number: SSN EIN RAN

Is applicant at least 18 years old? Yes No

Applicant's Name:

Applicant's Authorized Rep.:

Street or Mailing Address:

City: State: Zip:

Telephone Number:

Spouse's Name:

Spouse's Identification Number:

Name of Parent or Guardian:

Policy #:

Agency/Agent Name and Address:

Agency Code: Effective Crop Year: State:

National/State Request:

(National) I request insurance coverage for my share of the Category B crops (except forage production) specified below with a designated county in all added counties where the crops are insurable.

(State) I request insurance coverage for my share of the Category B crops (except forage production) specified below with a designated county in all added counties within the state where the crops are insurable.

In addition to my share on this policy, I am insuring:

My landlord’s share

My tenant’s share under my crop policy

I am providing a Power of Attorney or Lease Agreement as evidence of my authority to insure their share.

Applicant's Email Address:

List all person(s) with a substantial beneficial interest in you: If none, state NONE.

Please complete a SOCIAL SECURITY NUMBER AND EMPLOYER IDENTIFICATION NUMBER REPORTING form for additional substantial beneficial interest entities when applicable.

Substantial Beneficial Interest Details

This policy shall continue for each succeeding crop year until cancelled or terminated as provided in the policy.

Crop and Coverage Table

Authority to sign crop insurance documents on behalf of the insured

I grant the person(s) listed below the authority to sign any and all crop insurance documents on my behalf. I understand that by authorizing such persons to sign documents on my behalf I am legally bound by all terms and conditions of such documents and of the crop insurance contract. I also understand that granting the following person(s) the authority to sign on my behalf does not obligate that person(s) to the terms and conditions of my crop insurance contract. I further understand that this authorization may be revoked by me at any time upon written notice, signed and delivered to my Approved Insurance Provider.

This policy shall continue for each succeeding crop year until cancelled or terminated as provided in the policy.

Supplemental Coverage Option Endorsement

In addition to Section 3B(2) of the Basic Provisions, I hereby elect this Supplemental Coverage Option Endorsement, and by this election I understand:

(1) I must have purchased a policy under the Common Crop Insurance Policy Basic Provisions and applicable Crop Provisions to elect this Endorsement and must also purchase this Endorsement with the same Approved Insurance Provider as my Common Crop Insurance Policy

(2) I may elect coverage under this Endorsement and the Farm Service Agency's Agricultural Risk Coverage Program, but the same acreage of the crop cannot be covered under both programs.

(3) I may elect coverage under this Endorsement and Stacked Income Protection Plan for the upland cotton, but the same acreage cannot be insured under both.

(4) If at any time my Common Crop Insurance Policy for the crop is cancelled or terminated, coverage under this endorsement is automatically terminated, coverage under this endorsement is automatically cancelled or terminated.

(5) That by electing this Endorsement, it will continue from year to year unless I or you cancel or change my election by written notice on or before the cancellation date or my coverage is otherwise canceled or terminated under the terms of my policy.

(6) Separate Administrative Fees will be assessed for each policy insured under this Endorsement

Part I: Policy Transfer to NAU Country

I hereby request cancellation of my insurance policy with for the crop(s) and crop year(s) shown above because I have applied for insurance with another Approved Insurance Provider.

Policy number

I hereby authorize and direct the shown above to furnish any information relative to my insurance policy to the Assuming Approved Insurance Provider listed below.

Part II: Policy Transfer to NAU Country Insurance Company

By submission of this form, we agree to provide crop insurance to this applicant for the crop(s) and crop year specified above unless this form is not executed on or before the established cancellation date for any of the crop(s) shown, in which case insurance will be provided for such crop(s) for the following crop year.

Certification Statement

I certify that to the best of my knowledge and belief all of the information on this form is correct.