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pdfUnited States
Department of
Agriculture
Risk
Management
Agency
Product
Administration
and Standards
Division
FCIC 24040
(11-2006)
2007
Document and
Supplemental
Standards
Handbook
(DSSH)
NOVEMBER 2006
TABLE OF CONTENTS
FCIC 24040
SECTIONS
1
PURPOSE…..………………….……….……………………………………………………………….1
2
SUMMARY OF CHANGES ………………………………………………………………………….1
3
SPECIAL INSTRUCTIONS...………………………………………………………………………….1
4
OPERATING POLICY………………………………………………………………………………….2
5
ACRONYMS..…………………………………………………………………………………………...3
6
REPORTS (reserved)………………………………………………………………………………….4
7
DOCUMENTS………..……..…………………………………………………………………………..5
8
DEFINITIONS ……………………………………………………………………………………..…….7
9
RESPONSIBILITIES…….……………………………………………………………………………..8
10
FORM STANDARDS ELEMENTS DEFINITIONS AND EXPLANATIONS…………….…….....9
11
ELECTRONIC FORMS………..……..………………………………………………………………12
12
SUBMISSION REQUIREMENTS FOR NON-REINSURED SUPPLEMENTAL (NRS) CROP
INSURANCE POLICIES……………………………………………………………………….…… 13
13
REVIEW OF NRS CROP INSURANCE POLICIES……………………………………….………14
EXHIBITS
1
CONDITIONS OF ACCEPTANCE STATEMENTS…………………….…………………………16
2
CERTIFICATION STATEMENT……….…………………………………………………………….17
3
COLLECTION OF INFORMATION AND DATA (PRIVACY ACT) ……….…………………….18
4
NONDISCRIMINATION STATEMENT…………………………………………….……………….19
5
APPLICATION FORM ……………….………………………………………………….…………..20
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NOVEMBER 2006
TABLE OF CONTENTS
FCIC 24040
EXHIBITS
6
APPLICATION/CANCELLATION AND TRANSFER FORM..…………………………………..23
7
APPLICATION/ACREAGE REPORT FORM….………………………………………………..…26
8
ACREAGE REPORT FORM.………………………………………………………………………..29
9
POLICY CHANGE FORM....……….………………………………………………………………..31
10
SOCIAL SECURITY NUMBER (SSN) AND
EMPLOYER IDENTIFICATION NUMBER (EIN) REPORTING FORM.………………………..34
11
POLICY CONFIRMATION AND/OR SCHEDULE OF INSURANCE………….………………..36
12
POWER OF ATTORNEY ..………………………………………………………………………..…38
13
ASSIGNMENT OF INDEMNITY……………………………………………………………………..40
14
CONTINUOUS HAIL AND FIRE EXCLUSION OPTION FORM….…………………………..…42
15
ANNUAL REQUEST TO EXCLUDE HAIL AND FIRE…………………….……………………..45
16
TRANSFER OF COVERAGE AND RIGHT TO AN INDEMNITY...………………………….….48
17
HIGH-RISK LAND EXCLUSION OPTION…..…………………………………………………..…51
18
PRODUCTION CERTIFICATION WORKSHEET..……………………………………………..…53
19
CROP INSURANCE WITHDRAWAL OF CLAIM..………………………………………………..55
20
REQUEST FOR POLICY CANCELLATION AND TRANSFER OF EXPERIENCE DATA…..56
21
REQUEST FOR RMA ASSIGNED IDENTIFICATION NUMBER.………..……………………..58
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NOVEMBER 2006
FCIC 24040
U.S. DEPARTMENT OF AGRICULTURE
WASHINGTON, D.C. 20250
RISK MANAGEMENT AGENCY DIRECTIVE
SUBJECT:
NUMBER: 24040
DATE:
November 17, 2006
DOCUMENT AND SUPPLEMENTAL
STANDARDS HANDBOOK (DSSH)
OPI:
Product Administration and Standards
Division (PASD)
APPROVED: Tim B. Witt /s/Tim B. Witt
Deputy Administrator, Product Management
1
PURPOSE
This directive provides the form standards and procedures for use in the sales and
service of any eligible crop insurance contract and the standards and procedures for
submission and review of non-reinsured supplemental policies in accordance with the
Standard Reinsurance Agreement (SRA).
2
3
SUMMARY OF CHANGES
A
Revised formatting requirements
B
Spousal name and identification number are non-substantive on the Acreage
Report and Schedule of Insurance
C
Provided language that the identification numbers may be masked by approved
insurance providers on the policy confirmation and schedule of insurance
D
Revised Power of Attorney format introductory paragraph
E
Refer applicable portion of Actual Production History (APH) Certification
Statement refers to the Certification Statement, Exhibit 2
F
Modified font size requirement
G
Clarified Landlord/Tenant requirements
SPECIAL INSTRUCTIONS
A
This directive is effective on the date issued and will remain in effect until
superseded or slip-sheeted.
B
RMA will amend this directive as needed to revise or issue new standards and
procedures to create forms to administer programs reinsured by FCIC under
authority of The Federal Crop Insurance Act (7 U.S.C. 1502 et. seq.).
C
The Documents Supplemental Standards Handbook (FCIC 24040) issued June
2006 is superseded by this directive.
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FCIC 24040
OPERATING POLICY
A
Form standards contained in this handbook are required to contain all items
identified as "Substantive".
[See the Exhibit Section for specific document requirements.]
B
Any form standards containing an interest rate for late premium payment cannot
be higher than the rates stated in the Code of Federal Regulations.
C
Form standard item entries may be formatted as line entries, column headings,
boxes, or blocks, as appropriate. Headings for form entries may be abbreviated,
and explanation provided in the form completion instructions.
D
The text for all documents should be developed with an 8-point font size when
possible and no less than a 6-point font. This will assist the applicants/insureds
in reading and understanding documents presented to them.
E
When combining forms issued under these standards into one form, the
combined form must meet the applicable standards in place for each individual
form.
F
Questions regarding these form standards and procedures should be directed to
the RMA Product Administration and Standards Division, Underwriting Standards
Branch at (816) 926-7387.
G
Standards contained in this handbook are not applicable to approved insurance
provider (AIP) administrative forms that do not affect the policy provisions, e.g.
direct deposit of an insured’s indemnity.
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FCIC 24040
ACRONYMS
ACT
The Federal Crop Insurance Act (7 U.S.C 1502 et seq.)
AIP
Approved Insurance Provider
APH
Actual Production History
BIA
Bureau of Indian Affairs
CFR
Code of Federal Regulations
CIH
Crop Insurance Handbook
DAS
Data Acceptance System
DSSH
Document and Supplemental Standards Handbook
EIN
Employer Identification Number
FCIC
Federal Crop Insurance Corporation
FSA
Farm Service Agency
FSN
Farm Serial Number
NRS
Non-Reinsured Supplemental
PASD
Product Administration and Standards Division
RMA
Risk Management Agency
SBI
Substantial Beneficial Interest
SRA
Standard Reinsurance Agreement
SSN
Social Security Number
USC
United States Code
USDA
United States Department of Agriculture
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FCIC 24040
REPORTS (Reserved)
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FCIC 24040
DOCUMENTS
A
B
This directive contains form standards and procedures for the following
documents:
(1)
Application [See Exhibit 5]
(2)
Application/Cancellation and Transfer [See Exhibit 6]
(3)
Application/Acreage Report [See Exhibit 7]
(4)
Acreage Report [See Exhibit 8]
(5)
Policy Change [See Exhibit 9]
(6)
Social Security Number (SSN) and Employer Identification Number (EIN)
Reporting Form [See Exhibit 10]
(7)
Policy Confirmation and/or Schedule of Insurance [See Exhibit 11]
(8)
Power of Attorney [See Exhibit 12]
(9)
Assignment of Indemnity [See Exhibit 13]
(10)
Continuous Hail and Fire Exclusion Option Form [See Exhibit 14]
(11)
Request to Exclude Hail and Fire [See Exhibit 15]
(12)
Transfer of Right to an Indemnity [See Exhibit 16]
(13)
High-Risk Land Exclusion Option [See Exhibit 17]
(14)
Production Certification Worksheet [See Exhibit 18]
(15)
Crop Insurance Withdrawal of Claim [See Exhibit 19]
(16)
Request for Policy Cancellation and Transfer of Experience Data [See
Exhibit 20]
(17)
Request for RMA Assigned Identification Number [See Exhibit 21]
Required Statements:
(1) The Collection of Information and Data (Privacy Act) Statement [See Exhibit
3] and the Nondiscrimination Statement [See Exhibit 4] must be included on
any form the individual signs or provided to the individual on separate form,
for each form that is signed by the individual. A copy must be maintained by
the Approved Insurance Provider (AIP).
(2) The Certification Statement [See Exhibit 2] must be included on any form that
the insured signs that collects information from the insured. (e.g.,
application, acreage report) Not applicable to appraisal worksheets.
C
Form standards not contained in the DSSH are found in other RMA handbooks
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FCIC 24040
such as: the Loss Adjustment Manual (LAM), Crop Loss Adjustment Standards
Handbooks, Crop Insurance Handbook (CIH), Written Agreement Handbook
(WAH), Adjusted Gross Revenue Standards Handbook and other applicable
issuances approved by RMA. Section 508(h) private product submissions
subsequently approved by the FCIC Board of Directors may also specify form
standards. Form standards provided in other applicable issuances are
considered “Substantive” unless otherwise noted.
D
Policies, Options and Endorsements as issued by RMA are the standards that
AIP’s must meet.
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FCIC 24040
DEFINITIONS
A
The Act - The Federal Crop Insurance Act (7 U.S.C. 1501 et seq.), as amended.
B
Agent - An individual licensed by the State in which an eligible crop insurance
contract is sold and serviced for the reinsurance year, and who is under contract
with a company or its designee to sell and service such eligible crop insurance
contracts.
C
Applicant – A person who has submitted an application for crop insurance under
the authority of the Act.
D
Approved Insurance Provider (AIP) - A legal entity, including the company, which
has entered into a Standard Reinsurance Agreement with FCIC for the applicable
reinsurance year.
E
Authorized Representative - Any person authorized by the insured to conduct
crop insurance business on the insured's behalf (i.e., Power of attorney,
authorized representative of a corporation, etc.).
F
Document – A form developed according to RMA standards for policies,
endorsements, procedures, and other material used for the purpose of
administering the programs in accordance with the Standard Reinsurance
Agreement.
G
Insured – The named person as shown on the application accepted by the AIP.
This term does not extend to any other person having a share or interest in the
crop (for example; a partnership, landlord, or any other person) unless
specifically indicated on the accepted application.
H
Non-Substantive - A term used by RMA informing the AIP that the item(s) may be
included on a form at the AIP’s discretion.
I
Person – An individual, partnership, association, corporation, estate, trust, or
other legal entity, and wherever applicable, a State, political subdivision, or an
agency of a State. “Person” does not include the United States Government or
any agency thereof.
J
Substantive - A term used by RMA informing the AIP that the item(s) must be
included on a form.
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FCIC 24040
RESPONSIBILITIES
A
B
The RMA Product Administration and Standards Division will:
(1)
Establish and issue minimum form standards for documents to affected
parties.
(2)
Provide guidance and clarification as needed regarding form standards
for documents.
(3)
Maintain DSSH (update existing standards, develop new standards,
incorporate recommended changes, etc.).
AIPs will:
(1)
Develop documents in accordance with RMA standards and other RMA
form standards issuances.
(2)
Assure that the applicable document contains all substantive statements.
(3)
Submit documents, document completion instructions, and applicable
computation results of documents, upon request to the RMA PASD or
other USDA oversight agency for review of compliance with these and other
RMA form standards issuances.
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FCIC 24040
FORM STANDARDS ELEMENT DEFINITIONS AND EXPLANATIONS
This section provides explanations for items contained in the form standards Exhibits.
A Identification Number:
(1) The Social Security Number (SSN), Employer Identification Number (EIN) or
RMA assigned number; and
(2) Form completion procedures must provide instructions to enter:
(a) The appropriate identification number; and
(b) The correct identification number.
B Identification Type:
Must contain the following:
Check one:
□ SSN
□ EIN
□ Assigned Number (Form Instructions should explain RMA Assigned or BIA)
AIPs may use alternate format for allowing policyholder/applicant identification type
provided all types are provided (SSN/EIN/Assigned), refer to Section 4C, e.g. circle
applicable type.
C Type of Entity:
(1) Form completion procedures must provide instructions to enter the specific type of
entity (i.e., partnership; trust; individual; corporation; etc.), not entity code;
(2) This entry is verified for accuracy during applicable RMA, USDA oversight
agencies, or AIP reviews; and at loss adjustment time;
(3) Entity descriptions are provided in the CIH; and
(4) Applicable entity codes are provided in SRA Appendix III.
D Substantial Beneficial Interest (SBI) Holder:
For persons with a substantial beneficial interest in the insured as identified on the
application: the entity type, identification number and identification type is not
required on each individual form if it is collected on the SSN/EIN Reporting Form
(see Exhibit 10).
E Added County Election:
(1) Guidelines to administer this election are found in the CIH.
(2) If AIPs elect to include this option on the application, one or both of the following
statements must appear on the application as “Substantive”:
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FCIC 24040
[ ] Yes [ ] No 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.
[ ] Yes [ ] No 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.
F Agent Code:
(1) If an AIP assigns an agent code, it is “Substantive” and is required on the
applicable form, as follows:
I.B. Agent February 1, 2006
(Agent’s Signature) (Date)
12RMA34
(Code Number)
(2) If an AIP does not assign an agent code, then the agent completing the form
must provide his/her name as shown in the following example, it is “Substantive”
and is required on the applicable form, as follows:
I.B. Agent February 1, 2006
(Agent’s Signature) (Date)
I.B. Agent
(Print Name of Agent Completing Form)
G Special Instructions for Inclusion of Collection of Information and Data (Privacy Act)
Statement (See Exhibit 3) on Forms:
(1) The Privacy Act statement must be printed on the document or provided to the
applicant/insured each time a document is signed that collects information for the
applicant/insured.
(2) If the Privacy Act statement is provided as a separate document, evidence of
receipt of this statement must be shown by securing the signature and date of
applicant/insured on a copy retained by the AIP. This process must be completed
for each document that requires the Privacy Act statement.
(3) If the Privacy Act statement is on the back of the form, add “See Reverse Side of
Form” for statement required by Privacy Act of 1974 on the front of the form.
(Substantive)
H State and County Name:
(1) The entry for "State and County Name" must be the state and county name
where insurance attaches.
(2) Form completion procedures must provide this information.
I AIP name and address: (AIP’s full name and address as specified in the SRA)
(1) The AIP may select item (a) or (b) to fulfill this “substantive” requirement:
(a) Provide the AIP’s name and address with the policy or policy jacket at time of
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FCIC 24040
issue; or
(b) Provide the AIP’s name and address on all forms.
J Landlord/Tenant insuring other’s share:
(1) Guidelines are found in the CIH.
(2) The form must clearly state that the tenant will insure the landlord’s share or
landlord will insure the tenant’s share.
(3) Form instructions must provide that evidence must be provided of the other
party’s approval.
(4) Insuring a landlord/tenant is on a crop/county/policy basis.
(5) Suggested formats follow (Substantive):
(a) “Is applicant insuring the tenant’s share? Yes
“Is applicant insuring the landlord’s share? Yes
(b)
No “
No “; or
“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”. (Substantive); or
(c) Enter statement in the Remarks/Other entry section that landlord/tenant is
insuring other’s share under the crop policy. Form Completion instructions
must provide explanation of landlord/tenant insuring other’s share; or
(d) AIPs may use the alternate language with the form’s completion instructions
providing explanations, in accordance with Section 4C of the CIH.
K All substantive form standards are required unless not authorized by a specific policy,
e.g. Landlord/Tenant questions not required for Group Risk Protection (GRP).
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FCIC 24040
ELECTRONIC FORMS
Congress passed the Freedom to E-File Act, P.L. 106-222, requiring the Department of
Agriculture to establish an electronic filing and retrieval system to enable producers to
file paperwork electronically with the Department.
A
General Information:
(1)
Section 5 of the Freedom to E-File Act required FCIC to develop a plan
and submit it to Congress by December 1, 2000, which would allow
agriculture producers:
(a) To obtain, over the internet, from AIPs, all forms and other
information concerning the program under the jurisdiction of FCIC in
which the producer is a participant;
(b) To file electronically all paperwork required for participation in the
program; and
(c) To have the option to file electronically, or in paper form in
accordance to the Freedom to E-File Act; Section 3(b).
(2)
B
AIP’s are required to comply with the Freedom to E-File Act and provide
electronic accessibility to producers.
(a)
AIPs were required to establish an E-Business Implementation Plan
(EBIP) by December 1, 2001.
(b)
The EBIP requires an established back-up system to the primary
system or the facility where information is housed to ensure
computer failure does not deny access to records.
(c)
AIP’s must meet these requirements prior to approval for an SRA.
Electronic forms must be generated in accordance with the standards contained
in this handbook and other applicable RMA standards in accordance with the AIP
EBIP.
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FCIC 24040
SUBMISSION REQUIREMENTS FOR NON-REINSURED SUPPLEMENTAL (NRS)
CROP INSURANCE POLICIES
A
B
What to Submit:
(1)
Three complete copies of the new or revised policy and related material.
(2)
Any policies previously approved by RMA that are changed in ANY
manner.
(3)
All supplemental policies as required under the SRA.
When to Submit:
NRS policies not requesting RMA reinsurance must be submitted no later than
120 days prior to the first sales closing date.
C
Submit to:
Deputy Administrator, Product Management
Risk Management Agency
Attention: Product Administration and Standards Division STOP 0812
6501 Beacon Drive
Kansas City, Missouri 64133-4676
D
Quality of Documents Submitted:
All documents must be edited, checked for spelling, and be in final form. RMA
will not specifically review documents for spelling, grammar, punctuation, format,
etc.
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FCIC 24040
REVIEW OF NRS CROP INSURANCE POLICIES
The AIP shall not sell a contract of insurance or similar instrument, which is written in
conjunction with an eligible insurance contract and not reinsured by FCIC, unless it has
complied with the requirements of 7 C.F.R. 400.713. FCIC will not provide reinsurance
for an eligible insurance contract if the AIP sold a contract or similar instrument that
FCIC determines to have shifted risk to, or increases the risk, reduces or limits the rights
of the insured with respect to the underlying policy or causes disruption in the market
place of, such eligible insurance contract reinsured under the SRA. Supplemental
policies will be reviewed to determine that it is not likely to increase or shift risk to the
underlying policy or plan of insurance, reduce or limit the rights of insureds, or cause
market disruption.
A
RMA’s PASD will have 60 days to review the policies, provided all information
required by RMA is included in the initial submission of the policy package.
B
The AIP must maintain and make available at the request of FCIC, the
underwriting information pertaining to a non-reinsured contract or similar
instrument of insurance, including the policy number and all SSNs, EINs, or RMA
assigned number(s) related to the eligible crop insurance contract.
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FCIC 24040
DOCUMENT AND SUPPLEMENTAL
STANDARDS HANDBOOK
EXHIBITS
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EXHIBIT 1
FCIC 24040
CONDITIONS OF ACCEPTANCE STATEMENTS
CONDITIONS OF ACCEPTANCE: This application is accepted and insurance attaches in
accordance with the policy unless: (1) The Federal Crop Insurance 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 the 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.
Yes No
(a)
Are you now indebted and the debt is delinquent for insurance coverage under the
Federal Crop Insurance 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 insurance coverage under the authority of the Federal Crop Insurance
Act terminated for violation of the terms of the contract or regulations, or for failure to pay
your indebtedness?
(d)
Are you disqualified or debarred under the Federal Crop Insurance Act, the regulations of
the Federal Crop Insurance Corporation, or the United States Department of Agriculture?
(e)
Have you ever entered into an agreement with the Federal Crop Insurance Corporation
or with the Department of Justice that you would refrain from participating in programs
under the authority of the Federal Crop Insurance Act and that agreement is still
effective?
(f)
Do you have like insurance on any of the above crop(s)?
I understand that if coverage for any crop is currently terminated or would have subsequently
terminated for indebtedness had this application been filed after the termination date, no
coverage can be provided and I am ineligible for any benefits under the Federal Crop Insurance
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, insurance shall be in effect for the crop(s) and crop years specified and
shall continue for each succeeding crop year, unless otherwise specified in the policy, until
canceled, terminated or voided. The insurance contract, which includes the accepted
application, is defined in the regulation published at 7 CFR chapter IV. No 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.
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EXHIBIT 2
FCIC 24040
CERTIFICATION STATEMENT
I certify that to the best of my knowledge and belief all of the information on this form is correct. I
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. §1006 and §1014; 7 U.S.C. §1506; 31 U.S.C. §3729, §3730 and any other applicable
federal statutes).
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EXHIBIT 3
FCIC 24040
COLLECTION OF INFORMATION AND DATA (PRIVACY ACT)
To the extent that the information requested herein relates to your individual capacity as
opposed to your business capacity, the following statements are made in accordance with the
Privacy Act of 1974, as amended (5 U.S.C. 552a). The authority for requesting information to
be furnished on this form is the Federal Crop Insurance Act (7 U.S.C. 1501 et seq.) (Act) and
the Federal crop insurance regulations contained in 7 C.F.R. chapter IV.
Collection of the social security account number (SSN) or the employer identification number
(EIN) is authorized by section 506 of the Act and is required as a condition of eligibility for
participation in the Federal crop insurance program. The primary use of the SSN or EIN is to
correctly identify you, and any other person with an interest in you or your entity of 10 percent or
more, as a policyholder within the systems maintained by the Federal Crop Insurance
Corporation (FCIC). Furnishing the SSN or EIN is voluntary; however, failure to furnish that
number will result in denial of program participation and benefits.
Your policy also specifies other information that must be provided. The principle purposes of this
information are to provide insurance; reinsurance; determine eligibility; determine the correct
parties to the agreement; determine and collect premiums or other monetary amounts (including
administrative fees and over payments); and pay benefits. The routine uses of this information
include: (1) Referral to the appropriate agency, whether Federal, State, local or foreign including
the Department of Justice, charged with the responsibility of investigating or prosecuting a
violation of law, or of enforcing or implementing a statute, rule regulation or order issued
pursuant thereto, of any record within this system when information available indicates a
violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether
arising by general statute or particular program statute or by rule, regulation or order issued
pursuant thereto; (2) Disclosure to a court, magistrate or administrative tribunal, or to opposing
counsel in a proceeding before a court, magistrate or administrative tribunal, of any record
within the system that constitutes evidence on that proceeding, or which is sought in the course
of discovery, to the extent that FCIC determines that the records sought are relevant to the
proceeding; (3) Disclosure to a congressional office in response to any inquiry from the
congressional office made at the request of that individual; (4) Disclosure to Approved
Insurance Providers (AIP) for any purpose relating to the sale, service, and administration of the
Federal crop insurance program and the policies insured under the authority of the Act; (5)
Disclosure to other Federal agencies and contractors, cooperators, and partners of FCIC for the
purpose of conducting research, development, analyses, and evaluation into all aspects relating
to new and existing crop insurance programs and other risk management tools; (6) Disclosure
to contractors or other Federal agencies to conduct research and analysis to identify patterns,
trends, anomalies, instances and relationships of AIP’s, agents, loss adjusters and policyholders
that may be indicative of fraud, waste, and abuse; (7) Disclosure to AIPs, contractors, and other
applicable Federal agencies to determine whether information has been accurately provided to
FCIC and the AIPs and to determine compliance with program requirements; and (8) Disclosure
to AIPs, contractors, cooperators, partners of FCIC, and other Federal agencies for any purpose
relating to the sale, service, administration, analysis and evaluation of the Federal crop
insurance program.
Furnishing other information is also voluntary. However, failure to report the information
specified in your policy may result in rejection of any claim for indemnity, replanting payment, or
other benefit; ineligibility for insurance; a unilateral determination of any monetary amounts due;
or any remedy provided in the policy.
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EXHIBIT 4
FCIC 24040
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and
activities on the basis of race, color, national origin, age, disability, and where applicable, sex,
marital status, familial status, parental status, religion, sexual orientation, genetic information,
political beliefs, reprisal, or because all or a part of an individual’s income is derived from any
public assistance program. (Not all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication of program information (Braille,
large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice
and TDD).
To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights,1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or
(202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
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EXHIBIT 5
FCIC 24040
APPLICATION FORM
1
2
APPLICANT INFORMATION
A
"Applicant's Name” (Substantive)
B
"Applicant's Authorized Representative” (Substantive)
C
"Street or Mailing Address” (Substantive)
D
"City and State” (Substantive)
E
"Zip Code” (Substantive)
F
"Applicant's Telephone Number” (Substantive)
G
"Policy Number" (Substantive)
H
" Identification Number” (Substantive)
I
“Type of Identification Number” (Substantive)
J
"Type of Entity” (Substantive)
K
“Spouse’s Name” (Substantive)
L
“Spouse’s Identification Number” (Substantive)
M
“Is applicant at least 18 years old? Yes
N
Landlord/Tenant insuring other’s share (Substantive – refer to Section 10J)
No
“(Substantive)
CROP INFORMATION
A
"Effective Crop Year" (Substantive)
B
"Name of Crop" (Substantive)
C
"State and County Name” (Substantive)
D
"Options" or "Optional Coverage" (Substantive)
E
"Type, Class, Etc." (Substantive)
F
"Price Election” or “Amount of Insurance" (Substantive)
G
"Level Election" or "Coverage Level" (Substantive)
H
"Plan of Insurance" (Substantive)
I
“Added County Election” [See Section 10E for “Substantive” and “NonSubstantive” information that pertains to this item.]
20
NOVEMBER 2006
J
3
EXHIBIT 5
FCIC 24040
“Designated County” (Substantive)
OTHER INFORMATION AND SIGNATURES
A
"Name of Previous AIP (if any)" (Substantive)
B
"Policy Number under Previous AIP (if any)" (Substantive)
C
Conditions of Acceptance Statements [Exhibit 1] above Applicant's Signature
line: (Substantive)
“I certify that the information and answers on this application are correct to my
knowledge and belief; that none of the reasons for rejection in items 1
through 4 of the ‘Conditions of Acceptance’ apply; and that I am aware of and
understand the requirements of the Collection of Information and Data (Privacy
Act), as well as all other provisions contained on this application.”
D
"Applicant's Signature" (Substantive)
E
"Date" (of Applicant's Signature)” (Substantive)
F
"Agent’s Signature, Date and Code Number” (Substantive)
G
"Agent’s Telephone Number" (Substantive)
H
"Page ____of_____" (Substantive)
I
" List all persons or entities with a substantial beneficial interest in you as defined
in the applicable policy provisions” (include landlords or tenants insured under
the applicant). If none, state NONE. (See reverse side for additional space.)
(Substantive)
Required Information: (Title and Items 1 – 5 are Substantive)
1.
2.
3.
4.
5.
4
Name
Address
Telephone number
Identification Number and Type of Identification Number
Type of Entity
J
"Approved Insurance Provider’s Name and Address” (Substantive)
K
"Form Identification Number (alpha and/or numeric)” (Substantive)
L
"Form Title" (Substantive)
REQUIRED STATEMENTS
A
Conditions of Acceptance Statements [(Substantive) see Exhibit 1, refer to item
3C above]
B
Certification Statement [(Substantive) see Exhibit 2]
C
Privacy Act Statement [(Substantive) see Exhibit 3]
21
NOVEMBER 2006
D
5
EXHIBIT 5
Nondiscrimination Statement [(Substantive) see Exhibit 4]
(RESERVED)
22
FCIC 24040
NOVEMBER 2006
EXHIBIT 6
FCIC 24040
APPLICATION/CANCELLATION AND TRANSFER FORM
1
GENERAL INFORMATION
This form must be designed and/or have explicit form completion procedures that
provide the applicant's original signature is on the application portion that is retained by
the assuming AIP. The form should be designed to allow all application information to
appear in duplicate form with the duplicate copy provided to ceding AIP. The
cancellation/transfer portion of the form must be in a box [see Section 4] and have the
following statement at the top of the box. "TO BE COMPLETED ONLY IF CANCELING
PREVIOUS POLICY AND TRANSFERRING EXPERIENCE AND INSURANCE
COVERAGE FROM ANOTHER APPROVED INSURANCE PROVIDER." (Substantive)
2
3
APPLICANT INFORMATION
A
"Applicant's Name" (Substantive)
B
"Applicant's Authorized Representative" (Substantive)
C
"Street or Mailing Address" (Substantive)
D
"City and State" (Substantive)
E
"Zip Code" (Substantive)
F
"Applicant's Telephone Number" (Substantive)
G
"Policy Number" (Substantive)
H
" Identification Number” (Substantive)
I
“Type of Identification Number” (Substantive)
J
"Type of Entity" (Substantive).
K
“Spouse’s Name” (Substantive)
L
“Spouse’s Identification Number” (Substantive)
M
"Is applicant at least 18 years old? Yes
N
Landlord/Tenant insuring other’s share (Substantive – refer to Section 10J)
No
CROP INFORMATION
A
"Effective Crop Year" (Substantive)
B
"Name of Crop" (Substantive)
C
"State and County Name" (Substantive)
D
"Options" or "Optional Coverage" (Substantive)
E
"Type, Class, or Etc." (Substantive)
23
“(Substantive)
NOVEMBER 2006
4
EXHIBIT 6
FCIC 24040
F
"Price Election” or “Amount of Insurance" (Substantive)
G
"Level Election" or "Coverage Level" (Substantive)
H
"Plan of Insurance" (Substantive)
I
“Added County Election” [See Section 10E for “Substantive” and “NonSubstantive” information that pertains to this item.]
J
“Designated County” (Substantive)
CANCELLATION/TRANSFER OF EXPERIENCE INFORMATION
"TO BE COMPLETED (CHECK BOX) ONLY IF CANCELING PREVIOUS POLICY AND
TRANSFERRING THE EXPERIENCE AND INSURANCE COVERAGE FROM
ANOTHER APPROVED INSURANCE PROVIDER." (Substantive)
□ Yes, I request cancellation of my previous policy and request transfer of experience
and insurance coverage to the assuming Approved Insurance Provider shown on
this application.
"I hereby request cancellation of my crop insurance policy for the crop(s) and
crop year as shown on this application. I understand that if this form is not
executed on or before the cancellation date for any crop year listed, the
cancellation of insurance on such crop(s) will not become effective until the
following crop year. I hereby authorize and direct the ceding Approved Insurance
Provider shown to furnish any information relative to my insurance policy to
(Assuming Approved Insurance Provider’s name). I understand that if coverage for
any crop(s) is now terminated or would have subsequently terminated for
indebtedness had this transfer not occurred no coverage can be provided by the
Assuming Approved Insurance Provider." (Substantive)
NOTE: Item 4 above must be placed within a box above the application’s insured’s
signature line and date.
5
OTHER INFORMATION AND SIGNATURES
A
Conditions of Acceptance statements [Exhibit 1] above Applicant's Signature line:
"I certify that the information and answers on this application are correct to my
knowledge and belief; that none of the reasons for rejection in items 1 through 4
of the “Conditions of Acceptance” apply; and that I am aware of and understand
the requirements of the Collection of Information and Data (Privacy Act), as well
as all other provisions contained on this application." (Substantive)
B
"Applicant's Signature" (Substantive)
C
"Date" (of Applicant's Signature) (Substantive)
24
NOVEMBER 2006
EXHIBIT 6
FCIC 24040
D
"Agent’s Signature, Date and Code Number” (Substantive)
E
"Agent's Address" (Substantive)
F
"Agent's Telephone Number" (Substantive)
G
"Page ____of_____" (Substantive)
H
"List all persons or entities with a substantial beneficial interest in you as defined
in the applicable policy provisions (include landlords or tenants insured under the
applicant). If none, state NONE.” (Substantive)
Required Information: (Title and Items 1 – 5 are Substantive)
1. Name
2. Address
3. Telephone number
4. Identification Number and Type of Identification Number
5. Type of Entity
6
7
I
“Approved Insurance Provider’s Name and Address” (Substantive)
J
"Form Identification Number (alpha and/or numeric)" (Substantive)
K
"Form Title" (Substantive)
REQUIRED STATEMENTS
A
Conditions of Acceptance Statements [(Substantive) see Exhibit 1]
B
Certification Statement [(Substantive) see Exhibit 2]
C
Privacy Act Statement [(Substantive) see Exhibit 3]
D
Nondiscrimination Statement [(Substantive) see Exhibit 4]
RESERVED
25
NOVEMBER 2006
EXHIBIT 7
FCIC 24040
APPLICATION/ACREAGE REPORT FORM
1
2
APPLICANT INFORMATION
A
"Applicant's Name” (Substantive)
B
"Applicant's Authorized Representative” (Substantive)
C
"Street or Mailing Address” (Substantive)
D
"City and State” (Substantive)
E
"Zip Code” (Substantive)
F
"Applicant's Telephone Number” (Substantive)
G
"Policy Number” (Substantive)
H
" Identification Number” (Substantive)
I
“Type of Identification Number” (Substantive)
J
"Type of Entity” (Substantive)
K
“Spouse’s Name” (Substantive)
L
“Spouse’s Identification Number” (Substantive)
M
"Is applicant at least 18 years old? Yes
N
Landlord/Tenant insuring other’s share (Substantive – refer to Section 10J)
No
“(Substantive)
CROP INFORMATION
A
"Effective Crop Year” (Substantive)
B
"Name of Crop” (Substantive)
C
"State and County Name” (Substantive)
D
"Plan of Insurance” (Substantive)
E
"Options" or "Optional Coverage” (Substantive)
F
"Type, Class, Etc." (Substantive)
G
"Section", "Township”, and "Range” and “Other Land Identifier” (Substantive)
H
"FSA Farm Serial Number” (Substantive)
I
"Planted Acres of Insured Crop” (Substantive)
Divide column and label "Whole" and "10ths or 100ths" underneath "Acres of
insured crop." (Non-Substantive)
26
NOVEMBER 2006
3
EXHIBIT 7
FCIC 24040
J
"Insured's Share” (Substantive)
K
"Name of Other Person(s) Sharing in the Crop” (Substantive)
L
"Date Planting Completed” (Substantive)
M
"Practice” (Substantive)
N
"Classification Number (Rate Class)” (Substantive)
O
"Unit Number" (Substantive)
P
"Price Election” or “Amount of Insurance” (Substantive)
Q
"Level Election" or "Coverage Level" (Substantive)
R
“Added County Election” [See Section 10E for “Substantive” and “NonSubstantive” information that pertains to this item.]
S
“Designated County” (Substantive)
OTHER INFORMATION AND SIGNATURES
A
"Name of Previous AIP (if any)" (Substantive)
B
"Policy Number under Previous AIP (if any)” (Substantive)
C
"Uninsured Acres" Create block area for this with an area large enough to record
crop, acres, legal locations (Section/Township/Range and Other Land Identifier/
FSN) of the uninsured acreage, and the reason acreage is uninsured.
(Substantive)
D
"Remarks Section” (Substantive)
Create an area large enough to document pertinent information and the number
of uninsured acres if a specific block area for recording uninsured acres is not
developed.
E
Conditions of Acceptance Statements [Exhibit 1] above Applicant's Signature
line: (Substantive)
"I certify that the information and answers on this application/acreage report are
correct to my knowledge and belief; that none of the reasons for rejection in
items 1 through 4 of the “Conditions of Acceptance” apply; and that I am aware of
and understand the requirements of the Collection of Information and Data
(Privacy Act), as well as all other provisions contained on this application."
F
"Applicant's Signature” (Substantive)
G
"Date" (of Applicant's Signature) (Substantive)
H
"Agent’s Signature, Date and Code Number” (Substantive)
27
NOVEMBER 2006
EXHIBIT 7
I
"Agent's Address” (Substantive)
J
"Agent's Telephone Number” (Substantive)
K
"Page ____of_____” (Substantive)
L
"List all persons or entities with a substantial beneficial interest in you as defined
in the applicable policy provisions” (include landlords or tenants insured under
the applicant). If none, state NONE. (See reverse side for additional space.)
(Substantive)
Required Information: (Title and items 1-5 are Substantive)
1.
2.
3.
4.
5.
4
5
FCIC 24040
Name
Address
Telephone number
Identification Number and Type of Identification Number
Type of Entity
M
“Approved Insurance Provider’s Name and Address” (Substantive)
N
"Form Identification Number (alpha and/or numeric)” (Substantive)
O
"Form Title” (Substantive)
REQUIRED STATEMENTS
A
Conditions of Acceptance Statements [(Substantive) see Exhibit 1]
B
Certification Statement [(Substantive) see Exhibit 2]
C
Privacy Act Statement [(Substantive) see Exhibit 3]
D
Nondiscrimination Statement [(Substantive) see Exhibit 4]
(RESERVED)
28
NOVEMBER 2006
EXHIBIT 8
FCIC 24040
ACREAGE REPORT FORM
1
2
3
INSURED INFORMATION
A
"Insured's Name" (Substantive)
B
"Street or Mailing Address" (Substantive)
C
"City and State" (Substantive)
D
"Zip Code" (Substantive)
E
“Spouse’s Name” (Non-Substantive)
F
“Spouse’s Identification Number” (Non-Substantive)
G
"Crop Year" (Substantive)
H
"Crops Insured" (List all crops insured whether reporting acres or not.)
(Substantive)
I
"Policy Number" (Substantive)
AGENT INFORMATION
A
"Agent's Name" (Substantive)
B
"Street or Mailing Address" (Substantive)
C
"City and State" (Substantive)
D
"Zip Code" (Substantive)
CROP INFORMATION
A
"Section," "Township," "Range," and “Other Land Identifier” (Substantive)
B
"FSA Farm Serial Number" (Substantive)
C
"Name of Crop" (Substantive)
D
"Planted Acres of Insured Crop" (Substantive)
Divide column and label "Whole" and "10ths or 100ths" underneath "Acres of
Insured Crop." (Non-Substantive)
E
"Insured's Share” (Substantive)
F
"Name of Other Person(s) Sharing in the Crop” (Substantive)
G
"Date Planting is Completed” (Substantive)
H
"Practice” (Substantive)
29
NOVEMBER 2006
4
EXHIBIT 8
I
"Type, Class, Etc." (Substantive)
J
“Options” or “Optional Coverage” (Substantive)
K
"Classification Number" (Substantive)
L
“Plan of Insurance" (Substantive)
M
"Unit Number" (Substantive)
N
"State and County Name" (Substantive)
FCIC 24040
OTHER INFORMATION AND SIGNATURES
A
"Uninsured Acres" Create block area with an area large enough to record crop,
acres, legal locations (Section/Township/Range and Other Land Identifier/FSN)
of the uninsured acreage, and the reason acreage is uninsured. (Substantive)
B
"Remarks Section” (Substantive)
Create an area large enough to document pertinent information and the number
of uninsured acres if a specific block area for recording uninsured acres is not
developed.
5
C
"Insured's Signature" (Substantive)
D
"Date" (of Insured's Signature) (Substantive)
E
"Agent’s Signature, Date and Code Number” (Substantive)
F
"Page____of_____” (Substantive)
G
“Approved Insurance Provider’s Name and Address” (Substantive)
H
"Form Identification Number (alpha and/or numeric)” (Substantive)
I
"Form Title” (Substantive)
REQUIRED STATEMENTS
A
Certification Statement [(Substantive) see Exhibit 2]
B
Privacy Act Statement [(Substantive) see Exhibit 3]
C
Nondiscrimination Statement [(Substantive) see Exhibit 4]
30
NOVEMBER 2006
EXHIBIT 9
FCIC 24040
POLICY CHANGE FORM
1
INSURED INFORMATION
A
"Insured's Name" (Substantive)
B
"Insured's Authorized Representative” (Substantive)
C
"State and County Name” (Substantive)
D
"Policy Number” (Substantive)
E
" Identification Number” (Substantive)
F
“Type of Identification Number” (Substantive)
G
“Spouse’s Name” (Substantive)
H
“Spouse’s Identification Number” (Substantive)
I
"List all persons or entities with a substantial beneficial interest in you as defined
in the applicable policy provisions” (include landlords or tenants insured under
the applicant). If none, state NONE. (See reverse side for additional space.)
(Substantive)
Required Information: (Title and Items 1-5 are Substantive)
1.
2.
3.
4.
5.
2
Name
Address
Telephone number
Identification Number and Type of Identification Number
Type of Entity
J
“Added County Election” [See Section 10E for “Substantive” and “NonSubstantive information that pertains to this item.]
K
“Designated County” (Substantive)
CHANGES
A
"Change Insurance □” (Substantive)
Form-completion procedures must provide instructions to check this box when
appropriate.
B
"Effective Crop Year” (Substantive)
C
"Name of Crop" (For identification purposes only; a crop cannot be added using a
policy change form.) (Substantive)
D
"Type, Class, Etc." (Substantive)
E
"Price Election” or “Amount of Insurance” (Substantive)
31
NOVEMBER 2006
3
EXHIBIT 9
FCIC 24040
F
"Level Election" or "Coverage Level” (Substantive)
G
"Plan of Insurance” (For identification purposes only; a plan of insurance cannot
be changed using a policy change form.) (Substantive)
H
"Options” or “Optional Coverage” (Substantive)
CANCELLATIONS
A
"Cancel Insurance □” (Substantive)
Form completion procedures must provide instructions to check this box when
appropriate.
4
B
"Effective Crop Year” (Substantive)
C
"Name of Crop” (Substantive)
D
"Options” or “Optional Coverage” (Substantive) [See note pertaining to optional
coverage at the end of this Exhibit.]
E
"Type, Class, Etc." (Substantive)
REASONS FOR CANCELLATION
"Reasons for Cancellation." Create item entries for Reason of Cancellation, similar to the
example below. (Substantive)
(Check One)
(Explain in Remarks)
□ Insured's Request
□ Mutual Consent
□ Death, Incompetence, or
Dissolution
□ Other
Provide form and completion procedures which instruct that the reason for cancellation must be
explained in the remarks section of the form.
5
OTHER CHANGES
A
B
C
D
E
F
G
"□ Successor-In-Interest" and "Effective Crop Year_________" (of the successorin-interest transaction.) (Substantive)
"□ Add or change insured's authorized representative” (Substantive)
"□ Change insured's address” (Substantive)
"□ Correct insured's identification number” (Substantive)
"□ Correct spelling of insured's name” (Substantive)
“□ Correct SBI’s identification number” (Substantive)
“□ Correct spelling of SBI’s name (Substantive)
These item entries are required in order to identify the type of change being initiated.
Form-completion procedures must provide instructions to convey this information.
32
NOVEMBER 2006
6
EXHIBIT 9
FCIC 24040
REMARKS SECTION
Create an area large enough to enter explanations or remarks. (Substantive)
7
8
OTHER INFORMATION AND SIGNATURES
A
"Insured's Signature” (Substantive)
B
"Date" (of Insured's Signature) (Substantive)
C
"Agent’s Signature, Date and Code Number” (Substantive)
D
"Form Identification Number (alpha and/or numeric)” (Substantive)
E
“Approved Insurance Provider’s Name and Address” (Substantive)
F
"Form Title" (Substantive)
SPECIAL FORM-DEVELOPMENT INFORMATION
“Options” or “Optional Coverages”
A
Purchasing Optional Coverages
If optional coverage is purchased or coverage is excluded (when permitted by the
policy) after basic coverage is established, the Policy Change form may be used
to add or exclude optional coverage. The application can also be used to add
optional coverage; however, it is recommended that the Policy Change form be
used to do this for an existing policy.
Form and completion procedures must include instructions for adding optional
coverage if this form is used to add optional coverage after the basic crop
coverage has already been purchased.
B
Cancellation of Optional Coverages
The Policy Change form will be used to cancel optional coverage that the insured
purchased or cancel coverage exclusion. This applies to all types of optional
coverage; e.g., potato options, and High-Risk Land Exclusion Option. Form and
completion procedures must include instructions to cancel optional coverage on
this form.
9
REQUIRED STATEMENTS
A
Certification Statement [(Substantive) see Exhibit 2]
B
Privacy Act Statement [(Substantive) see Exhibit 3]
C
Nondiscrimination Statement [(Substantive) see Exhibit 4]
33
NOVEMBER 2006
EXHIBIT 10
FCIC 24040
SOCIAL SECURITY NUMBER (SSN) AND
EMPLOYER IDENTIFICATION NUMBER (EIN) REPORTING FORM
1
2
3
4
GENERAL INFORMATION
A
Form Title is: “Social Security Number (SSN) and Employer Identification Number
(EIN) Reporting Form” (Substantive)
B
"(YEAR) and Succeeding Crop Years” (Substantive)
INSURED’S INFORMATION
A
"Name of Applicant/Insured” (Substantive)
B
"Insured’s Telephone Number” (Substantive)
C
"Insured’s Address" (Substantive)
D
"City and State" (Substantive)
E
"Zip Code" (Substantive)
F
"Policy Number" (Substantive)
G
" Identification Number” (Substantive)
H
“Type of Identification Number” (Substantive)
I
"Type of Entity" (Substantive)
J
“Spouse’s Name” (Substantive)
K
“Spouse’s Identification Number” (Substantive)
L
“Approved Insurance Provider’s Name and Address” (Substantive)
M
"Form Identification Number (alpha and/or numeric)” (Substantive)
AGENT INFORMATION
A
"Agent’s Name" (Substantive)
B
"Agent's Address" (Substantive)
C
"Agent’s Signature, Date and Code Number” (Substantive)
OTHER PERSON AND/OR ENTITY INFORMATION
"List all persons or entities with a substantial beneficial interest in the insured/applicant as
defined in the applicable policy provisions [(include landlords or tenants insured under the
applicant). If none, state NONE. (See reverse side for additional space) (Substantive)
Required Information: (Title and items 1-5 are substantive)
34
NOVEMBER 2006
1.
2.
3.
4.
5.
5
EXHIBIT 10
Name
Address
Telephone number
Identification Number and Type of Identification Number
Type of Entity
SIGNATURE BLOCK
"Signature of Applicant/Insured" and "Date" (Substantive)
6
REQUIRED STATEMENTS
A
Certification Statement [(Substantive) See Exhibit 2]
B
Privacy Act Statement [(Substantive) See Exhibit 3]
C
Nondiscrimination Statement [(Substantive) See Exhibit 4]
35
FCIC 24040
NOVEMBER 2006
EXHIBIT 11
FCIC 24040
POLICY CONFIRMATION AND/OR SCHEDULE OF INSURANCE
1
2
3
INSURED INFORMATION
A
"Insured’s Name" (Substantive)
B
“Street or Mailing Address” (Substantive)
C
“City and State” (Substantive)
D
“Zip Code” (Substantive)
E
" Insured’s Identification Number” (Substantive) 1
F
“Type of Identification Number” (Substantive)
G
“Spouse’s Name” (Substantive for Policy Confirmation) *1
(Non-Substantive for Schedule of Insurance)
H
“Spouse’s Identification Number” (Substantive for Policy Confirmation) *1
(Non-Substantive for Schedule of Insurance)
I
"Policy Number” (Substantive)
CROP INFORMATION
A
"Crop Insured" (Substantive)
B
"Crop Practice/Type/Variety" (Substantive)
C
"Price Election" (Substantive)
D
"Coverage Level” (Substantive)
E
"Options" or “Optional Coverage” (For example Hail/Fire, High-Risk Land
Exclusion, Potato Quality Option, etc.) (Substantive)
F
"Effective Crop Year" (Substantive)
G
“Plan of Insurance” (Substantive)
H
"State and County Name” (Substantive)
AGENT INFORMATION
A
"Agent’s Name" (Substantive)
B
"Agent’s Street or Mailing Address" Substantive)
C
"Agent’s City and State" (Substantive)
D
"Agent’s Zip Code" (Substantive)
*1 Identification Numbers may be masked by the AIP
36
NOVEMBER 2006
4
EXHIBIT 11
E
"Agent’s Code Number” (Substantive)
F
"Agent’s Telephone Number" (Substantive)
FCIC 24040
OTHER INFORMATION
A
"Form Title" (Substantive)
B
"Form Identification Number (alpha and/or numeric)" (Substantive)
C
"Approved Insurance Provider’s Name and Address" (Substantive)
D
"Date Issued" (Substantive)
E
"Amount of Administrative Fee Due the Approved Insurance Provider"
(Substantive)
F
"Amount of Subsidy Paid by RMA" (Substantive)
37
NOVEMBER 2006
EXHIBIT 12
FCIC 24040
POWER OF ATTORNEY
1
GENERAL INFORMATION
A personal Power of Attorney created by an attorney for an insured does not have to
adhere to form standards issued by RMA. However, if an AIP chooses to develop a
Power of Attorney form for use by their insureds, such forms should comply with the
“Substantive” standards listed below. Agent and loss adjuster use of a power of
attorney form may be limited by conflict of interest requirements contained in the
Standard Reinsurance Agreement, refer to Manager’s Bulletin MGR-05-019.
2
STATEMENTS
A
The following statements are “Substantive”:
"The undersigned does hereby make, constitute and appoint
of
in the
County of
and State of , the true and lawful attorney, for and in the name,
place and stead of the undersigned in connection with Insurance Policy and/or
Policy Number
.
The undersigned gives and grants unto said attorney full authority and power to
do and perform actions as initialed below fully ratifying and confirming all that
said attorney shall lawfully do or cause to be done by virtue hereof:
1.
2.
3.
4.
5.
6.
7.
8.
Making application for insurance.
Making crop acreage reports.
Giving notice of damage or loss.
Making claim for indemnity.
Making policy change.
Making transfers and cancellations.
Providing program required production reports.
Taking all actions related to the insurance coverage provided under the
above identified policy and/or policy number.
This Power of Attorney shall be filed at the office where the official insurance file
folder is maintained and shall remain in full force and effect until written notice of
its revocation has been received by the office maintaining the official insurance
file folder (such revocation shall be placed in the official insurance file folder).
This Power of Attorney is signed and dated at (City), (State) this
(YEAR).
day of
Print Witness Name
________________
Print Insured Name
_______________
Witness Signature
________________
Insured’s Signature
I hereby accept the foregoing appointment:
________________
Print Appointee Name
_________________
Appointee’s Signature
38
,
NOVEMBER 2006
EXHIBIT 12
FCIC 24040
ACKNOWLEDGMENT
(For use by Notary Public)
State of
County of
(Use acknowledgment if required by the State where acknowledgment is taken)
Signatures of the insured and the appointee must be notarized when required by law.
Witness signatures are not required if notarized.
3
OTHER INFORMATION AND SIGNATURES
A
"Notary Seal and Signature of Notary" (Substantive if required by State Law)
B
"Approved Insurance Provider’s Name and Address" (Substantive)
C
"Form Identification Number (alpha and/or numeric)" (Substantive)
D
"Form Title" (Substantive)
E
Privacy Act Statement [(Substantive) see Exhibit 3]
F
Nondiscrimination Statement [(Substantive) see Exhibit 4]
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NOVEMBER 2006
EXHIBIT 13
FCIC 24040
ASSIGNMENT OF INDEMNITY
1
2
INSURED INFORMATION
A
"Insured’s Name" (Substantive)
B
"Insured’s Authorized Representative" (Substantive)
C
"Street or Mailing Address" (Substantive)
D
"City and State" (Substantive)
E
"Zip Code" (Substantive)
F
"Policy Number" (Substantive)
G
"Effective Crop Year" (Substantive)
TERMS AND CONDITIONS
A
"The assignment must read as follows": (Substantive)
"The Insured assigns to (Name of Creditor) of (Mailing Address)
(City, State and Zip) the right and interest of any indemnity payment(s) which
may be payable to the insured under the insurance policy for the
county/commodity (ies) shown:” e.g., (1st Crop Name and County Name) (2nd
Crop Name and County Name) (Substantive)
The Name and Address of Creditor must be contained in above statement unless
listed on the form.
“CONDITIONS
(1)
This assignment will be binding upon the person(s) who succeed the
insured’s interest in the insurance policy.
(2)
Indemnity payments made under the insurance policy will be subject to a
deduction for any indebtedness due this Approved Insurance Provider by
the insured.
(3)
This assignment will not grant the Creditor any greater rights than originally
held by the insured.
(4)
The Creditor’s interest will be recognized upon Approved Insurance
Provider’s approval of this assignment and the Creditor will have the right to
submit the loss notices and other forms as required by the insurance policy.
(5)
The Approved Insurance Provider will determine the person(s) entitled to
any indemnity payment(s) and the payment(s) will be by joint check.
(6)
Cancellation of this assignment prior to and during the crop year stated
above will be accepted by the Approved Insurance Provider only upon
notification in writing by the above identified Creditor(s). It is understood
and agreed that this assignment will be subject to the terms and conditions
40
NOVEMBER 2006
EXHIBIT 13
FCIC 24040
of the insurance policy.” (Followed by signatures of the Insured, Creditor
and Witnesses)
(7)
3
4
“If the assignment is not canceled according to item (6), the assignment will
cease at the end of the effective crop year.” (Substantive)
B
"The Approved Insurance Provider hereby approves the foregoing assignment”
(Followed by the Authorized Representative’s signature for the Approved
Insurance Provider and date) (Substantive)
C
"This assignment was filed with the Approved Insurance Provider on
at _ a.m. /p.m." (Substantive)
, (YEAR)
OTHER INFORMATION AND SIGNATURES
A
"Insured’s Signature and Date" (Substantive)
B
"Creditor’s Signature and Date" (Substantive)
C
"Witness Signature and Date" (Substantive) – Both the Insured’s and Creditor’s
signature and date as provided in item A & B must contain a Witness signature
and date.
D
"Approved Insurance Provider’s Authorized Representative Signature and Date"
(Substantive)
E
"Approved Insurance Provider’s Name and Address" (Substantive)
F
"Form Identification Number (alpha and/or numeric)" (Substantive)
G
"Form Title" (Substantive)
REQUIRED STATEMENTS
A
Privacy Act Statement [(Substantive) See Exhibit 3]
B
Nondiscrimination Statement [(Substantive) See Exhibit 4]
41
NOVEMBER 2006
EXHIBIT 14
FCIC 24040
CONTINUOUS HAIL AND FIRE EXCLUSION OPTION FORM
1
2
INSURED INFORMATION
A
"Insured’s Name" (Substantive)
B
"Street or Mailing Address" (Non-Substantive)
CROP INFORMATION
A
"The Hail and Fire Exclusion applies to the following crop(s):
“(Substantive)
3
B
"State and County Name Where Insurance Attaches" (Substantive)
C
"First Effective Crop Year" (Substantive)
D
"Multiple Peril Crop Insurance (MPCI) Policy Number" (Substantive)
TERMS AND CONDITIONS
The following statements are “Substantive” except for the calculation example which is
“Non-substantive.”
A
"Hail and Fire will be excluded on a crop basis as insured causes of loss from
your MPCI policy for a reduced premium for each crop year the following terms
and conditions are met."
"The terms of this option apply to the first crop year requested and are
continuous for each succeeding crop year as provided below. This option can be
canceled or crops can be deleted if a request is submitted in writing on or before
the applicable cancellation date for the crop(s), or crops can be added if a written
request is submitted on or before the applicable sales closing date for the
crop(s)."
B
"For the first crop year of this option:
(1)
The Hail and Fire Exclusion Option must be signed: (a) within 72 hours of
the date a private Hail and Fire policy is first in effect or (b) on or before
the date the MPCI coverage attaches for a crop year after the first crop
year a multi-season hail and fire policy is in effect.
(2)
This option is effective only if the crop has not been damaged to the
extent that a MPCI indemnity may be claimed on any unit of the insured
crop."
C
"For each crop year, Hail and Fire insurance coverage must be in effect (and
premiums earned) on all planted insurable acreage of the crop insured under the
MPCI policy and the total dollar amount of hail and fire insurance liability must
equal or exceed the total MPCI liability for that crop acreage."
D
"For each crop year, you must provide a copy of the annual hail and fire
declaration sheet showing the required amount of hail and fire coverage for the
42
NOVEMBER 2006
EXHIBIT 14
FCIC 24040
crop year or other proof that the required amount of hail and fire coverage has
attached for the crop year."
E
"An appraisal for uninsured causes will be made when the crop is damaged by
hail and/or fire, and the average percent damage to the crop insurance unit
exceeds the coverage level percentage determined by subtracting the coverage
level percentage from 100. This excess percentage amount will be multiplied by
the guarantee per acre divided by your coverage level percentage and the result
will be the appraisal for uninsured causes."
“For example:
The average percent hail damage to the crop insurance
unit = 45%. MPCI coverage level = 65%. Per-acre
guarantee = 100.0 bu.
Step 1: 1.00 - .65 = .35
Step 2: .45 - .35 = .10 (excess percentage)
Step 3: .10 x 100.0 bu. (per-acre guarantee)
Step 4: 10. ÷ .65 = 15.4 bu. per-acre appraisal for
uninsured causes. "
"EXCEPT THAT:
If hail and/or fire occurs and the original hail and fire liability under a private hail
and fire policy has been reduced below the MPCI insurance coverage, due to
another cause of loss insured under the MPCI insurance policy, the hail and/or
fire indemnity will be divided by the original hail and fire liability. This result will
be multiplied by the MPCI insurance guarantee per acre divided by your
coverage level percentage and the result will be the appraisal for uninsured
causes."
4
OTHER INFORMATION AND SIGNATURE
A
"Information for the first-year hail/fire exclusion request." (Substantive)
(1)
"Hail and Fire Coverage Effective Date" (Substantive)
(2)
"Name of Hail and Fire Insurance Company (ies) and Policy Number(s)"
(Substantive)
B
"Name and Address of Approved Insurance Provider" (Substantive)
C
The following statement is required above the insured’s signature: (Substantive)
"I, the insured, will provide any information the Approved Insurance Provider may
require or Authorized Representative(s) of the Approved Insurance Provider
access to any information that the Approved Insurance Provider may require
regarding any hail and fire policy(ies) I have in effect for any crop year that this
option is in effect." (Substantive)
D
"Insured’s Signature and Date" (Substantive)
E
"Agent’s Signature, Date and Agent Code Number” (Substantive)
F
"Form Identification Number (alpha and/or numeric)” (Substantive)
43
NOVEMBER 2006
5
EXHIBIT 14
FCIC 24040
G
"Form Title” (Substantive)
H
"Approved Insurance Provider’s Name and Address" (Substantive)
REQUIRED STATEMENTS
A
Privacy Act Statement [(Substantive) see Exhibit 3]
B
Nondiscrimination Statement [(Substantive) see Exhibit 4]
44
NOVEMBER 2006
EXHIBIT 15
FCIC 24040
ANNUAL REQUEST TO EXCLUDE HAIL AND FIRE
1
2
INSURED INFORMATION
A
"Insured’s Name" (Substantive)
B
"Street or Mailing Address" (Non-Substantive)
C
"City, State and Zip Code" (Non-Substantive)
CROP INFORMATION
A
"The Request to Exclude Hail and Fire applies to the following crop(s):
“(Substantive)
3
B
"Effective Crop Year" (Substantive)
C
"Multiple Peril Crop Insurance (MPCI) Policy Number" (Substantive)
TERMS AND CONDITIONS
The following statements are “Substantive” except for the calculation example which is
“Non-substantive”.
A
"Hail and Fire will be excluded on a crop basis as insured causes of loss from
your MPCI Insurance Policy for a reduced premium for the effective crop year
provided the following terms and conditions are met."
B
"For the effective crop year of this request:
(1)
The Request to Exclude Hail and Fire must be signed: (a) within 72 hours
of the date a private hail and fire policy is in effect or (b) on or before the
date MPCI insurance coverage attaches for a crop year after the first crop
year a multi-season hail and fire policy is in effect on a crop.
(2)
This request is effective only if the crop has not been damaged to the
extent that a MPCI insurance indemnity may be claimed on any unit of the
insured crop."
C
"Hail and Fire insurance coverage must be in effect (and premiums earned) on all
planted insurable acreage of the crop insured under the MPCI insurance policy
and the total dollar amount of hail and fire insurance liability must equal or
exceed the total MPCI insurance liability for that crop acreage."
D
"The Insured must provide a copy of the hail and fire declaration sheet showing
the required amount of hail and fire coverage for the effective crop year or other
proof that the required amount of hail and fire coverage as attached for the
effective crop year."
E
"An appraisal for uninsured causes will be made when the crop is damaged by
hail and/or fire, and the average percent damage to the crop insurance unit
exceeds the coverage level percentage determined by subtracting the coverage
45
NOVEMBER 2006
EXHIBIT 15
FCIC 24040
level percentage from 100. This excess percentage amount will be multiplied by
the guarantee per acre divided by your coverage level percentage, and the result
will be the appraisal for uninsured causes."
“For example:
The average percent hail damage to the crop insurance
unit = 45%. MPCI coverage level = 65%. Per-acre
guarantee = 100.0 bu.
Step 1: 1.00 - .65 = .35
Step 2: .45 - .35 = .10 (excess percentage)
Step 3: .10 x 100.0 bu. (per-acre guarantee)
Step 4: 10 ÷ .65 = 15.4 bu. per-acre appraisal for
uninsured causes."
"EXCEPT THAT:
If hail and/or fire occurs and the original hail and fire liability under a private hail
and fire policy has been reduced below the MPCI insurance coverage, due to
another cause of loss insured under the MPCI Policy, the hail and/or fire
indemnity will be divided by the original hail and fire liability. This result will be
multiplied by the MPCI insurance guarantee per acre divided by your coverage
level percentage and the result will be the appraisal for uninsured causes."
4
OTHER INFORMATION AND SIGNATURE
A
"Hail and Fire Coverage Effective Date" (Substantive)
B
"Name of Hail and Fire Insurance Company (ies) and Policy Number(s)”
(Substantive)
C
"Name and Address of Approved Insurance Provider “(Substantive)
D
The following statement is required above the Insured’s Signature. (Substantive)
"I, the insured, will provide any information the Approved Insurance Provider may
require or Authorized Representative(s) of the Approved Insurance Provider
access to any information that the Approved Insurance Provider may require
regarding any hail and fire policy(ies) I have in effect for the crop year of this
request. I certify that the information reported above is true and correct"
(Substantive)
5
E
"Insured’s Signature and Date" (Substantive)
F
"Agent’s Signature, Date and Agent Code Number” (Substantive)
G
"Form Identification Number” (alpha and/or numeric) (Substantive)
H
"Form Title" (Substantive)
I
"Approved Insurance Provider’s Name and Address" (Substantive)
J
"Page
of
“(Substantive)
REQUIRED STATEMENTS
46
NOVEMBER 2006
EXHIBIT 15
A
Privacy Act Statement [(Substantive) see Exhibit 3]
B
Nondiscrimination Statement [(Substantive) see Exhibit 4]
47
FCIC 24040
NOVEMBER 2006
EXHIBIT 16
FCIC 24040
TRANSFER OF COVERAGE AND RIGHT TO AN INDEMNITY
1
2
3
GENERAL INFORMATION
A
"Transferor’s Name" (Substantive)
B
"Transferor’s Street and Mailing Address” (Substantive)
C
“Policy Number" (Substantive)
D
"Section,” “Township,” “Range,” “Other Land Identifier” or “FSA Farm Serial
Number" (Substantive)
CROP INFORMATION
A
"Crop" (Substantive)
B
"Crop Year" (Substantive)
C
"Unit Number" (Substantive)
D
The following is “Substantive”:
(1)
Is all of the insured acreage and all of the insured share on this unit being
transferred? Yes ( ) No ( )
(2)
Statement “a” below may be used alone. If both statements are used the
form should indicate: “Check one of the boxes”
□a
Make check payable jointly to insured and transferee(s). Check
will be mailed to the insured’s address (unless an assignment of
indemnity is on file); or
□b
Make checks payable to transferee(s) only. Check will be mailed
to address shown in 3B.
OTHER INFORMATION
A
"Transferee(s) Name(s)" (Substantive)
B
"Transferee(s) Address, City, State, and Zip Code" (Substantive)
C
“Transferee’s Identification Number” (Substantive)
D
“Type of Identification Number” (Substantive)
E
"Acreage Transferred" (Substantive)
F
"Share Transferred" (Substantive)
G
"Effective Date of Transfer" (Substantive)
H
"Nature of Transfer" (Substantive)
48
NOVEMBER 2006
4
EXHIBIT 16
FCIC 24040
I
"Form Identification Number (alpha and/or numeric)” (Substantive)
J
"Form Title" (Substantive)
K
"Approved Insurance Provider’s Name and Address" (Substantive)
TERMS AND CONDITIONS
The following information is “Substantive”.
A
5
Acceptance by the Approved Insurance Provider of the above-described transfer
shall transfer the insured’s right to an indemnity to the above-named transferee
subject to:
(1)
Receipt by the Approved Insurance Provider of satisfactory evidence that
said transfer occurred before the end of the insurance period; i.e., (a) the
date harvest was completed on the unit, (b) the calendar date for the end
of the insurance period, or (c) the date the entire crop on the unit was
destroyed, as determined by the Approved Insurance Provider.
(2)
The terms of the above-identified insurance contract, including any
outstanding assignment of indemnity made by the transferor prior to the
date of transfer.
(3)
All other terms and provisions set forth herein.
B
The Approved Insurance Provider shall not be liable for any more indemnity than
existed before the transfer occurred.
C
The insurance policy of the transferor covers the share hereby transferred only to
the end of the insurance period for the current crop year.
D
The “Transferee” and the “Transferor” shall be jointly and severally liable for any
unpaid premium earned for the current crop year on the acreage and share
transferred. The premium for the unit has been paid: Yes ( ) No ( )
E
Total premium on this unit
F
Premium on acreage transferred
$________
G
Premium on retained acreage
$________
H
Premium paid with transfer $________
$________
REQUIRED SIGNATURES
A
"Transferor’s Signature and Date” (Substantive)
B
"Transferee(s) Signature and Date” (Substantive)
C
"Agent’s Signature, Date and Agent Code Number” (Substantive)
49
NOVEMBER 2006
6
EXHIBIT 16
REQUIRED STATEMENTS
A
Privacy Act Statement [(Substantive) see Exhibit 3]
B
Nondiscrimination Statement [(Substantive) see Exhibit 4]
50
FCIC 24040
NOVEMBER 2006
EXHIBIT 17
FCIC 24040
HIGH-RISK LAND EXCLUSION OPTION
1
2
3
INSURED INFORMATION
A
"Insured’s Name” (Substantive)
B
"Policy Number” (Substantive)
C
"Street or Mailing Address” (Substantive)
D
"City, State and Zip Code” (Substantive)
E
"County Name” (Substantive)
F
" Identification Number” (Substantive)
G
“Type of Identification Number” (Substantive)
CROP INFORMATION
A
"Crop(s)” (Substantive)
B
"Crop Year” (Substantive)
TERMS AND CONDITIONS
The following information must be on the form. (Substantive)
Upon our approval of this option, we agree to amend your multiple peril crop insurance
policy to exclude from crop insurance coverage all high-risk land for the identified crop(s)
and county(ies) in which you have a share, subject to the following terms and conditions:
A
The option must be submitted to us on or before the final date for accepting
applications for the initial crop year in which you wish to exclude high-risk land.
B
By signing this option, you are declining crop insurance coverage under the
general crop insurance policy and the crop endorsement on your high-risk land.
C
As used in this option, high-risk land is any land to which a high risk classification
applies as contained in the actuarial document(s).
D
This option may be canceled by either you or us for any succeeding crop year by
giving written notice on or before the cancellation date provided by the policy,
preceding such crop year.
E
You must report, on the acreage report for each crop year, the acreage of the
crop planted on high-risk land.
F
In the event of a loss on any insured unit, you must provide separate production
records showing planted acreage and harvested production for any acreage
which is excluded from crop insurance coverage under this option.
G
All other provisions of the policy not in conflict with this option are applicable.
51
NOVEMBER 2006
4
5
6
EXHIBIT 17
FCIC 24040
REQUIRED SIGNATURES
A
"Insured’s Signature and Date” (Substantive)
B
"Agent’s Signature, Date and Agent Code Number” (Substantive)
OTHER INFORMATION
A
"Form Identification Number" (alpha and/or numeric) (Substantive)
B
"Form Title” (Substantive)
C
"Approved Insurance Provider’s Name and Address" (Substantive)
REQUIRED STATEMENTS
A
Certification Statement [(Substantive) see Exhibit 2]
B
Privacy Act Statement [(Substantive) see Exhibit 3]
C
Nondiscrimination Statement [(Substantive) see Exhibit 4]
52
NOVEMBER 2006
EXHIBIT 18
FCIC 24040
PRODUCTION CERTIFICATION WORKSHEET
1
2
INSURED INFORMATION
A
"Insured’s Name” (Substantive)
B
“Street or Mailing Address” (Substantive)
C
“City and State” (Substantive)
D
“Zip Code” (Substantive)
E
"Telephone Number” (Substantive)
F
"Policy Number” (Substantive)
G
"Crop Year” (Substantive)
CROP INFORMATION
A
"Name of Crop” (Substantive)
B
"Crop Practice/Type/Variety" (Substantive)
C
"Unit Number” (Substantive)
D
"Section”, “Township”, “Range” or “Other Land Identifier” (Substantive)
E
"Land Other County Yes
F
"Other Entity (ies)” (Substantive)
G
"Record Type” (Substantive)
No “(Substantive)
1. Production Sold/Commercial Storage
2. On Farm Storage, Recorded Bin Measurement
3. Livestock Feeding Records
4. FSA Loan Record
5. Appraisals
6._Other
H
"Processor Number/Name and/or Number Trees or Vines” (Substantive)
I
"FSA Farm Serial Number” (Substantive)
J
"T-Yield” (Substantive)
K
"Crop Year of History” (Substantive)
L
"Total Production” (Substantive)
M
"Acres” (Substantive)
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NOVEMBER 2006
N
EXHIBIT 18
FCIC 24040
"Yield” (Substantive)
For items K, L, M and N above allow space to provide ten years of production
history.
3
4
5
O
"Preliminary Yield" (Substantive)
P
"Required: Field Review
Q
"New Producer □" (Substantive)
R
"Added Land/P/T/V □" (Substantive)
S
"State and County Name” (Substantive)
Inspection " (Substantive)
AGENT INFORMATION
A
"Agent’s Signature, Date and Agent Code Number” (Substantive)
B
"Agent’s Address" (Substantive)
C
“Agent’s Zip Code” (Substantive)
D
"Agent’s Telephone Number" (Substantive)
OTHER INFORMATION AND SIGNATURE
A
"Approved Insurance Provider’s Name and Address" (Substantive)
B
"Form Title" (Substantive)
C
"Form Identification Number (alpha and/or numeric)" (Substantive)
D
"Insured’s Signature" (Substantive)
E
"Date of Insured’s Signature” (Substantive)
F
"Page
of
" (Substantive)
REQUIRED STATEMENTS
A
APH Certification statement above Insured’s Signature line
“I understand this form may be reviewed or audited and that information
inaccurately reported or failure to retain records to support information on this
form may result in a recomputation of the approved APH yield.” Followed by the
Certification Statement, Exhibit 2. (Substantive)
B
Privacy Act Statement [(Substantive) see Exhibit 3]
C
Nondiscrimination Statement [(Substantive) see Exhibit 4]
54
NOVEMBER 2006
EXHIBIT 19
FCIC 24040
CROP INSURANCE WITHDRAWAL OF CLAIM
1
2
INSURED AND POLICY INFORMATION
A
"Insured’s Name” (Substantive)
B
"Claim Number” (Substantive)
C
"Policy Number” (Substantive)
D
“Name of Crop(s)” (Substantive)
E
“Unit Number(s)” (Substantive)
TERMS AND CONDITIONS
The following statement is required: (Substantive)
Withdrawal Statement: "For the unit number(s) listed above, I withdraw this claim
against the Approved Insurance Provider on this policy up to this date. I agree and
understand that signing this withdrawal in no way changes the terms of the policy or
affects any other loss that may subsequently occur."
3
4
OTHER INFORMATION AND SIGNATURE
A
"Insured’s Signature and Date” (Substantive)
B
"Approved Insurance Provider’s Name and Address" (Substantive)
C
"Form Identification Number (alpha and/or numeric)” (Substantive)
D
"Form Title” (Substantive)
E
"Agency Name and Address” (Substantive)
REQUIRED STATEMENTS
A
Privacy Act Statement [(Substantive) see Exhibit 3]
B
Nondiscrimination Statement [(Substantive) see Exhibit 4]
55
NOVEMBER 2006
EXHIBIT 20
FCIC 24040
REQUEST FOR POLICY CANCELLATION AND
TRANSFER OF EXPERIENCE DATA
1
REQUIRED LANGUAGE FOR REQUEST (Substantive)
A
"Part I
I hereby request cancellation of my insurance policy with (Ceding Approved
Insurance Provider Name) for the crop(s) and crop year(s) shown below because
I have applied for insurance with another Approved Insurance Provider. I
understand that if this form is not executed on or before the established
cancellation date for any crop listed, the cancellation of insurance on such
crop(s) will not become effective until the following crop year.”
2
3
B
"Crop(s)" to be canceled and transferred (Substantive)
C
"Crop Year" of crops being canceled and transferred (Substantive)
REQUIRED LANGUAGE TO AUTHORIZE (Substantive)
A
"I hereby authorize and direct the Ceding Approved Insurance Provider shown
above to furnish any information relative to my insurance policy to the Assuming
Approved Insurance Provider listed below. I understand that if coverage for any
crop(s) is now terminated or would have subsequently terminated for
indebtedness had this transfer not occurred, no coverage can be provided by the
Assuming Approved Insurance Provider."
B
"Signature of Policyholder and Date” (Substantive)
C
"Policy Number” (Substantive)
REQUIRED LANGUAGE TO PROVIDE INSURANCE (Substantive)
A
"Part II
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."
4
B
"Name of Assuming Agent” (Substantive)
C
"Assuming Agent’s Address, City, State and Zip Code” (Substantive)
D
"Signature of Approved Insurance Provider Representative Authorized to Accept
Applications" (Substantive)
E
"Date of Acceptance by Assuming Approved Insurance Provider” (Substantive)
F
"Assuming Approved Insurance Provider and Policy Issuing Company Code”
(Substantive)
OTHER INFORMATION AND SIGNATURES
56
NOVEMBER 2006
EXHIBIT 20
FCIC 24040
A
“Assuming Approved Insurance Provider’s Name and Address" (Substantive)
B
"Form Identification Number (alpha and/or numeric)” (Substantive)
C
"Form Title” (Substantive)
D
DISTRIBUTION: (Substantive)
"Original - Assuming Approved Insurance Provider (Forward to Ceding Approved
Insurance Provider upon Acceptance)
1st Copy - Assuming Approved Insurance Provider
2nd Copy - Assuming Agent
3rd Copy - Policyholder"
5
REQUIRED STATEMENTS
A
Privacy Act Statement [(Substantive) see Exhibit 3]
B
Nondiscrimination Statement [(Substantive) see Exhibit 4]
57
NOVEMBER 2006
EXHIBIT 21
FCIC 24040
REQUEST FOR RMA ASSIGNED IDENTIFICATION NUMBER
1
2
3
GENERAL INFORMATION
A
"(YEAR) and Succeeding Crop Years” (Substantive)
B
Applicable to insureds or persons with an SBI in the insured that are not legally
required to have a SSN or EIN number as defined in the applicable policy
provisions and CIH procedures. Such individuals may be assigned an
identification number that can be used for insurance purposes.
C
Persons requesting an assigned number must be eligible to receive Federal
benefits and must meet the requirements as provided in the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8
U.S.C. § 1611, which provides, with certain exceptions, only United States
citizens, United States non-citizen nationals and “qualified aliens” (and
sometimes only particular categories of qualified aliens) are eligible for Federal,
State, and local public benefits. Refer to Manager’s bulletin MGR-05-008 for
documentation requirements for non-citizens and AIP instructions.
D
Manager’s Bulletin MGR-05-008 provides Request for RMA Assigned
Identification Number procedures
APPLICANT INFORMATION
A
"Name of Applicant Requesting an Assigned Number" (Substantive)
B
"Applicant’s Telephone Number” (Substantive)
C
"Applicant’s Address” (Substantive)
D
"City and State” (Substantive)
E
"Zip Code” (Substantive)
F
"State and County Name” (Substantive)
G
"Policy Number (if applicable)” (Substantive)
H
“Identification Number of Policyholder (if request is for SBI)” (Substantive)
I
“Type of Identification Number for Policyholder (if request is for SBI)”
(Substantive)
J
"Policyholder’s Entity Type (if request is for SBI)” (Substantive)
K
"Approved Insurance Provider’s Name and Address" (Substantive)
L
"Document Type" (Substantive) – refer to Attachment A of Manager’s Bulletin
MGR-05-008
OTHER INFORMATION AND SIGNATURES
A
Certification statement [Exhibit 2] above Applicant's Signature line (Substantive)
58
NOVEMBER 2006
EXHIBIT 21
B
"Applicant's Signature and Date" (Substantive)
C
Statement above AIP representative’s signature line: (Substantive)
FCIC 24040
“I certify that (Name of Applicant) has met all other program requirements under
the authority of the Federal Crop Insurance Act (the Act) with the exception of
providing a SSN/EIN.”
4
D
" Approved Insurance Provider Representative Name, Signature, and Date”
(Substantive)
E
" Approved Insurance Provider Representative’s Address” (Non-Substantive)
F
" Approved Insurance Provider Representative’s Telephone Number”
(Substantive)
G
“Form Identification Number (alpha and/or numeric)” (Substantive)
H
“Form Title” (Substantive)
SIGNATURE BLOCK
"Signature of Insured/Policyholder (if Applicant is not policyholder) and Date"
(Substantive)
5
REQUIRED STATEMENTS
A
Certification Statement [(Substantive) see Exhibit 2]
B
Privacy Act Statement [(Substantive) see Exhibit 3]
C
Nondiscrimination Statement [(Substantive) see Exhibit 4]
59
| File Type | application/pdf |
| File Title | Microsoft Word - 2007 DSSH FCIC 24040 FINAL NOV 2006.doc |
| Author | erin.tecce |
| File Modified | 2008-05-28 |
| File Created | 2006-11-20 |