Download:
pdf |
pdfUnited States
Department of
Agriculture
Federal Crop
Insurance
Corporation
Risk
Management
Agency
Product
Administration
and Standards
Division
FCIC-24040
(06-2015)
Document and
Supplemental
Standards
Handbook
2016 and Succeeding Crop Years
United States Department of Agriculture
Risk Management Agency
Washington, D.C. 20250
TITLE: 2016 Document and Supplemental
Standards Handbook
NUMBER: FCIC 24040
EFFECTIVE DATE: 2016 and Succeeding
Crop Years
ISSUE DATE: 06/30/2015
OPI: Product Administration and Standards
Division
APPROVED: /s/ Tim B. Witt
SUBJECT:
2016 Document and Supplemental Standards
Handbook
Deputy Administrator for Product Management
REASON FOR ISSUANCE
This handbook provides the official FCIC approved form standards and procedures for use in the sale
and service of any eligible Federal crop insurance policy; required statements and disclosures; and the
standards for submission and review of non-reinsured supplemental policies in accordance with the
Standard Reinsurance Agreement for the 2016 and succeeding crop years.
June 2015
FCIC 24040
TP-1
SUMMARY OF CHANGES
The chart below identifies significant changes or modifications from prior issuances of the DSSH.
Minor changes and corrections are not included in this listing.
Affected forms must be modified to include these changes by December 31, 2015 and are effective for
policies with a contract change date after the directive’s publication.
DESCRIPTION OF ADDITIONS, DELETIONS, CHANGES OR
REFERENCE
CLARIFICATIONS
Para. 503 &
Added Nondiscrimination Statements for AIP Marketing Materials.
Exhibit 4
Incorporated Beginning Farmer and Rancher Form Standards from PM Bulletin
Exhibit 18
14-028.
Incorporated Late Payment of Debt Standards from PM Bulletin 15-010.
Exhibit 64
Added Fields to the Acreage Report to be consistent with CIH requirements and to
Exhibit 23
reflect new fields added to CIH.
Exhibit 16
Incorporated Form Standards for SCO.
Incorporated Form Standards for STAX. Modified Insured Information Part 1 to
be consistent with Form Standards for Applications; included the Added County
Exhibit 17
Election.
Para. 504 and Added new certification statement for USDA multiple benefits.
Exhibit 5
Added Native Sod Question to Acreage Report.
Exhibit 23
Added Adjusted Yield to the APH Database.
Exhibit 33
Changed Cross References from CIH to GSH, where applicable.
Throughout
Added “Protection Factor” to pricing fields in form standards.
Throughout
Changed requirement for “Street and/or Mailing Address” form standard to default
Para. 408 & 409
to mailing address if addresses differ.
Added Loss Adjustment Notice of Damage or Loss, Notice of Prevented Planting,
Exhibits 61-62
and Growing Season Inspection Forms from the LAM.
Removed Acronyms and Definitions and relocated to the GSH.
Para. 4
CONTROL CHART
TP Page(s)
Remove
Insert
TC Page(s)
Text Pages
Entire Handbook
Entire Handbook
Date
August 20, 2013
June 30 2015
Directive Number
FCIC 24040-04
FCIC 24040
FILING INSTRUCTIONS
This directive is effective on the date issued and will remain in effect until superseded or slip-sheeted.
RMA will amend this directive to administer programs reinsured by FCIC under authority of the
Federal Crop Insurance Act, 7 U.S.C. 1502 et. seq. FCIC-24040 Document and Supplemental
Standards Handbook issued June 2013 and its slip-sheets dated August 2013 are superseded by this
directive. All affected forms and statements must be updated by December 31, 2015.
June 2015
FCIC 24040
TP-2
Table of Contents
PART 1 GENERAL INFORMATION AND RESPONSIBILITIES
1
General Information ..................................................................................................................... 1
2
AIP Responsibilities ..................................................................................................................... 3
3
RMA Responsibilities .................................................................................................................. 3
4
Acronyms and Definitions ........................................................................................................... 3
5
Title VI of the Civil Rights Act of 1964 ...................................................................................... 4
6
The Privacy Act of 1974 .............................................................................................................. 4
7
Freedom to E-File ........................................................................................................................ 5
8-200
(Reserved) ................................................................................................................................... 6
PART 2 NON-REINSURED SUPPLEMENTAL CROP INSURANCE POLICIES
201
General Information ..................................................................................................................... 7
202
Submission Requirements ............................................................................................................ 7
203
Review of NRS Crop Insurance Policies ..................................................................................... 7
204-300 (Reserved)...................................................................................................................................... 8
PART 3 FORM STANDARDS OPERATING POLICY
301
Form Development....................................................................................................................... 9
302
Substantive v. Non-Substantive ................................................................................................... 9
303
Combined Form Standards ........................................................................................................... 9
304
Signatures ..................................................................................................................................... 9
305
Interest Rates .............................................................................................................................. 10
306
Required Statements................................................................................................................... 10
307-400 (Reserved) ................................................................................................................................. 10
PART 4 GENERAL FORM STANDARDS
401
Form Style .................................................................................................................................. 11
402
Identification Numbers ............................................................................................................... 11
403
Person Types .............................................................................................................................. 12
404
Substantial Beneficial Interest Holder........................................................................................ 12
405
Agent/Loss Adjuster Code ......................................................................................................... 13
406
State and County Name .............................................................................................................. 13
407
AIP Name and Address .............................................................................................................. 13
408
Street and Mailing Address ........................................................................................................ 13
409
City, State, Zip Code .................................................................................................................. 13
June 2015
FCIC 24040
TC- 3
Table of Contents
410
Added County Election .............................................................................................................. 14
411
Landlord/Tenant Insuring Other’s Share ................................................................................... 14
412
Price Election ............................................................................................................................. 15
413
Options, Elections, or Endorsements ......................................................................................... 15
414
Actuarial Fields .......................................................................................................................... 16
415-500 (Reserved).................................................................................................................................... 16
PART 5 GENERAL REQUIRED STATEMENTS AND DISCLOSURES
501
RMA Privacy Act Statement – Collection of Information and Data ......................................... 17
502
RMA Certification Statement .................................................................................................... 17
503
RMA Non-Discrimination Statement ........................................................................................ 17
504
USDA Multiple Benefit Statement ............................................................................................ 18
505
Native Sod .................................................................................................................................. 18
506
Conservation Compliance .......................................................................................................... 18
507
Conditions of Acceptance Statement ......................................................................................... 18
508-600 (Reserved).................................................................................................................................... 18
PART 6 AIP REQUIRED STATEMENTS AND DISCLOSURES
601
Anti-Rebating Certification Statement ....................................................................................... 19
602
Covenant Not to Sue Statement (Covenant) .............................................................................. 19
603
Non-Disclosure Statements (NDS) ............................................................................................ 20
604
Conflict of Interest (COI) Disclosure Statements ...................................................................... 21
605
Annual Controlled Business Certification ................................................................................. 27
606-700 (Reserved).................................................................................................................................... 30
FORM STANDARD EXHIBITS
General Statements and Disclosures
1 Conditions of Acceptance Statements ................................................................................................... 31
2 Certification Statement .......................................................................................................................... 32
3 Collection of Information and Data Statement ...................................................................................... 33
4 Non-Discrimination Statement for Forms and Marketing Materials ..................................................... 34
5 USDA Multiple Benefit Certification Statement ................................................................................... 35
6 Native Sod (Reserved) ........................................................................................................................... 36
7 Conservation Compliance- First Time Farmer (Reserved) ................................................................... 37
June 2015
FCIC 24040
TC- 4
AIP Statements and Disclosures
8 Anti-Rebating Certification ................................................................................................................... 38
9 Covenant Not to Sue .............................................................................................................................. 40
10 Approved Insurance Provider Non-Disclosure Statement .................................................................... 41
11 Individual Non-Disclosure Statement................................................................................................... 43
12 Conflict of Interest ................................................................................................................................ 44
13 Individual Controlled Business Certification ....................................................................................... 46
14 Affiliate Controlled Business Certification .......................................................................................... 48
Policy Forms
15 Application ........................................................................................................................................... 49
16 Supplemental Coverage Option Endorsement ...................................................................................... 51
17 STAX Application ................................................................................................................................ 53
18 BFR Application ................................................................................................................................... 55
19 Policy Cancellation ............................................................................................................................... 58
20 Policy Transfer/Application.................................................................................................................. 59
21 Policy Change ....................................................................................................................................... 61
22 Social Security Number and Employer Identification Number Reporting ........................................... 64
23 Acreage Report ..................................................................................................................................... 65
24 Summary of Coverage (Schedule of Insurance) ................................................................................... 68
25 Policy Confirmation (Policy Declaration) ............................................................................................ 70
26 Power of Attorney................................................................................................................................. 71
27 Assignment of Indemnity ..................................................................................................................... 73
28 Continuous Hail and Fire Exclusion Option......................................................................................... 75
29 Annual Request to Exclude Hail and Fire ............................................................................................ 78
30 High-Risk Land Exclusion Option ....................................................................................................... 80
31 Transfer of Coverage and Right to an Indemnity ................................................................................. 82
32 Production Report ................................................................................................................................. 85
33 Actual Production History Database .................................................................................................... 87
34 Withdrawal Claim for Indemnity.......................................................................................................... 89
35 Request for RMA Assigned Identification Number ............................................................................. 90
36 Request to Waive Administrative Fee for Limited Resource Farmer .................................................. 92
37 Unit Division Option ............................................................................................................................ 94
June 2015
FCIC 24040
TC- 5
Category B, C and D Forms
38 RMA Regional Office Determined Yield Request ............................................................................... 96
39 Summary of Revenue History Database ............................................................................................... 99
40 Revenue Report .................................................................................................................................. 101
41 Agreement to Combine Optional Units .............................................................................................. 103
42 APH Block Production ....................................................................................................................... 106
43 Producer’s Pre-Acceptance Worksheet .............................................................................................. 108
44 Perennial Crop Pre-Inspection Report ................................................................................................ 110
45 Perennial Crop Addendum Worksheet(s) ........................................................................................... 113
46 Weighted Average Age/Density Worksheet ....................................................................................... 121
47 Macadamia Orchard Inspection Report .............................................................................................. 122
48 Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet .............................................................. 124
49 Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report ............................................ 126
50 Forage Production Underwriting Report ............................................................................................ 131
51 Hybrid Seed Yield Request ................................................................................................................ 132
52 Hybrid Seed Corn Yield History Report ............................................................................................ 133
53 Hybrid Sorghum Seed Yield History Report ...................................................................................... 135
54 Added Land/New Crop/Practice/Type Request.................................................................................. 137
55 Irrigated Practice Guidelines .............................................................................................................. 139
Loss Adjustment Forms
56 Loss Adjustment Certification Form .................................................................................................. 143
57 Loss Adjustment Self-Certification Replant Worksheet .................................................................... 146
58 Loss Adjustment Claim Checklist ...................................................................................................... 150
59 Loss Adjustment Simplified Claims Qualification Process and Notice of Loss ................................ 152
60 Loss Adjustment Notice of Damage or Loss ...................................................................................... 156
61 Loss Adjustment Notice of Prevented Planting .................................................................................. 159
62 Growing Season Inspection Report .................................................................................................... 161
Other
63 New Producer Certification ................................................................................................................ 163
64 Request of Administrative Reinstatement .......................................................................................... 164
..
June 2015
FCIC 24040
TC- 6
June 2015
FCIC 24040
TC- 7
PART 1 GENERAL INFORMATION AND RESPONSIBILITIES
1
General Information
A.
Purpose
The FCIC is a wholly-owned government corporation established by the Federal Crop
Insurance Act, 7 U.S.C. 150. Its purpose is to promote the national welfare by improving
the economic stability of agriculture through a sound system of crop insurance and
providing the means for the research and experience helpful in devising and establishing
insurance. RMA is charged with regulation and oversight of the Act and the administration
of the crop insurance program on behalf of FCIC.
This handbook provides the official FCIC approved standards and procedures for use in the
sale and service of any eligible crop insurance policy; required statements and disclosures;
and the standards for submission and review of non-reinsured supplemental policies in
accordance with the Standard Reinsurance Agreement for the 2016 and succeeding crop
years.
B.
Source of Authority
Federal programs enacted by Congress and the regulations and policies developed by RMA,
USDA, and other Federal agencies provide the authority for program and administrative
operations; and basis for RMA directives. Administration of the Federal crop insurance
program is authorized by the following.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
June 2015
The Federal Crop Insurance Act, 7 U.S.C. 1501
The Food Security Act of 1985, 16 U.S.C. 3801 et seq.
Controlled Substance Act of 1970, 21 U.S.C. 801 et seq.
Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 42 U.S.C.
653a
Privacy Act of 1974, 7 U.S.C. 552a
Freedom to E-File Act, P.L. 106-222
7 CFR part 400
7 CFR part 12
Standard Reinsurance Agreement
FCIC 24040
1
1
General Information (Continued)
C.
Related Procedural Handbooks or Directives
The following table provides directives closely related to this handbook. However, other
RMA approved handbooks may refer to this handbook and be applicable.
HANDBOOK/
DIRECTIVE
Appendix
III
CIH
GSH
ITS
Standards, instructions, and information for electronic data reporting of
policyholder, commodity, and other information submitted by AIPs as required
by the SRA, LPRA, or other policy and procedure.
Provides the official FCIC-issued underwriting standards for policies covered
under the Common Crop Insurance Policy Basic Provisions and Area Risk
Protection Insurance, including the Catastrophic Risk Protection Endorsement
and Supplemental Coverage Option; and the Actual Production History
Regulation G.
Provides the official FCIC approved standards for policies administered by AIPs
under the General Administrative Regulations, 7 CFR Part 400; Common Crop
Insurance Policy Regulations, Basic Provisions, 7 CFR Part 457 including the
Catastrophic Risk Protection Endorsement, 7 CFR Part 402 and the Actual
Production History Regulation 7 CFR Part 400 Subpart G; the Area Risk
Protection Insurance Regulations, 7 CFR Part 407; Stacked Income Protection
Plan; the Rainfall and Vegetative Indices; and the Whole Farm Revenue
Protection Pilot Policy for the 2016 and succeeding crop years.
NUG
Provides instructions for administration of the ineligible tracking system.
Identifies loss adjustment standards and requirements for determining production
or revenue and adjusting crop insurance claims
Provides instructions for administration of the nursery crop provisions.
RI/VI
Procedures and information for administering the RI/VI plans of insurance.
STAX
Procedures for administering STAX (cotton only).
WAH
Provides standards and instructions for handling of actuarial change requests and
WAs.
WFRP
Provides information, procedures, and instructions for administering WFRP.
LAM
D.
RELATION/PURPOSE
Procedural Issuance Authority
This handbook is written and maintained by:
Office of Deputy Administrator for Product Management
Product Administration and Standards Division
USDA—Risk Management Agency
Beacon Facility—Mail Stop 0812
P.O. Box 419205
Kansas City, MO 64141-6205
For applicable RMA Regional or Compliance office contacts referenced throughout this
handbook, refer to www.rma.usda.gov/aboutrma/fields/.
June 2015
FCIC 24040
2
1
General Information (Continued)
E.
Procedural Questions
Questions regarding form standards and procedures must be directed to the RMA Product
Administration and Standards Division, Underwriting Standards Branch using the address
in sub-paragraph D above.
2
AIP Responsibilities
AIPs must develop documents in accordance with RMA standards and other RMA form standard
issuances. Upon request, each AIP must provide documents, document completion instructions,
and applicable computation results to the RMA or any other USDA oversight agency for review
of compliance with these and other RMA form standards.
3
RMA Responsibilities
The RMA must establish and maintain the DSSH to provide the minimum form standards for the
applicable crop insurance documents and provide guidance and clarification to the AIP as
requested.
4
Acronyms and Definitions
Refer to the General Administrative Handbook for applicable acronyms and definitions.
June 2015
FCIC 24040
3
5
Title VI of the Civil Rights Act of 1964
The USDA prohibits discrimination against its customers. Title VI of the Civil Rights Act of
1964 provides that “No person in the United States shall, on the ground of race, color, or national
origin, be excluded from participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity receiving Federal financial assistance.” Therefore,
programs and activities that receive Federal financial assistance must operate in a nondiscriminatory manner. Also, a recipient of RMA funding may not retaliate against any person
because he or she opposed an unlawful practice or policy, or made charges, testified or
participated in a complaint under Title VI.
It is the AIPs’ responsibility to ensure that standards, procedures, methods and instructions, as
authorized by FCIC in the sale and service of crop insurance contracts, are implemented in a
manner compliant with Title VI. Information regarding Title VI of the Civil Rights Act of 1964
and the program discrimination complaint process is available on the RMA public website at
http://www.rma.usda.gov/aboutrma/civilrights/complaint.html.
See Para. 503 for information about the RMA Non-Discrimination Statement.
6
The Privacy Act of 1974
The Privacy Act of 1974, 5 U.S.C. § 552a (Privacy Act), establishes a code of fair information
practices that governs the collection, maintenance, use, and dissemination of information about
individuals that is maintained in systems of records by federal agencies. A system of records is
a group of records under the control of an agency from which information is retrieved by the
name of the individual or by some identifier assigned to the individual.
In accordance with the Privacy Act, the Risk Management Agency is authorized by the Federal
Crop Insurance Act or other Acts, and the regulations promulgated thereunder, to solicit the
information requested on documents established by RMA, or by AIPs, that have been approved
by the FCIC, to deliver Federal crop insurance. The information is necessary for AIPs and
RMA to operate the Federal crop insurance program, determine program eligibility, conduct
statistical analysis, and ensure program integrity.
See Para. 501 for information about the RMA Privacy Act statement.
June 2015
FCIC 24040
4
7
Freedom to E-File
The Freedom to E-File Act, P.L. 106-222, requires the USDA to establish an electronic filing and
retrieval system to enable producers to file paperwork electronically with USDA.
A.
General Information
(1)
Section 5 of the Freedom to E-File Act required FCIC to develop a plan 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)
AIP’s are required to comply with the Freedom to E-File Act and provide electronic
accessibility to producers.
(a) AIPs are required to establish an E-Business Implementation Plan (EBIP).
(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.
B.
Generated Electronic Forms
Electronic forms must be generated in accordance with the standards contained in this
handbook, other applicable RMA standards and in accordance with the AIP established
EBIP.
June 2015
FCIC 24040
5
8-200 (Reserved)
June 2015
FCIC 24040
6
PART 2 NON-REINSURED SUPPLEMENTAL CROP INSURANCE POLICIES
201 General Information
NRS crop policies provide additional coverage, other than coverage for losses related to hail, to a
policy or plan of insurance that is reinsured by FCIC.
202 Submission Requirements
To submit a NRS crop policy three complete hard copies, or an electronic copy in a format
approved by RMA, of the new or revised policy and related material must be provided to RMA,
including any policies previously approved by RMA that are changed in any manner, and all nonreinsured supplemental policies as required under the SRA. All documents must be edited,
checked for spelling, and be in final form. RMA will not specifically review documents for
spelling, grammar, punctuation, formatting, etc.
NRS policies must be submitted no later than 120 days prior to the first sales closing date.
Submissions may be sent electronically at directorpdd@rma.gov, or by mail to:
Office of the Deputy Administrator for Product Management
Product Administration and Standards Division
USDA—Risk Management Agency
Beacon Facility—Mail Stop 0812
P.O. Box 419205
Kansas City, MO 64141-6205
203 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 crop insurance contract, unless it has complied with the requirements
of 7 C.F.R. 400.713. FCIC will not provide reinsurance for an eligible crop 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. RMA shall review supplemental policies 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.
(1)
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.
(2)
The AIP must maintain and make available at the request of FCIC, the underwriting
information pertaining to a non-reinsured supplemental 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.
June 2015
FCIC 24040
7
204-300 (Reserved)
June 2015
FCIC 24040
8
PART 3 FORM STANDARDS OPERATING POLICY
301 Form Development
AIPs are to control and develop all forms in accordance with RMA established policies and
procedures. The agent, contractor, or AIP representative is not permitted to develop any form for
use within policies administered by the AIP under the authority of FCIC, unless authorized by the
AIP. The AIP must meet the standards that are set forth in the policies, options and
endorsements as issued by RMA.
Standards contained in this handbook are not applicable to AIP administrative forms that do not
affect the policy provisions, such as a form for the direct deposit of an insured’s indemnity. AIPs
may develop additional forms based upon their internal needs, such as electronic transfer of
funds.
Form standards not contained in the DSSH may be in other RMA handbooks such as: the Crop
Loss Adjustment Standards Handbooks, Written Agreement Handbook, and other applicable
issuances approved by RMA. Section 508(h) private product submissions, or pilot programs
approved by the FCIC Board of Directors may also specify form standards. Any forms
developed in accordance with form standards from other directives must also adhere to the DSSH
Part 3 and Part 4, as applicable.
302 Substantive v. Non-Substantive
Form standards are required to contain all items identified as “Substantive” unless not authorized
by a specific policy. See the exhibits to this handbook for specific form requirements. Form
standards provided in other handbooks are considered “Substantive” unless otherwise noted.
Items identified as “Non-Substantive”, are not required, but are recommended forms standards
that may be included on the form at the AIPs discretion.
303 Combined Form Standards
AIPs, at their election, may combine two or more forms. If two or more forms issued are
combined into one form, the combined form must meet the applicable standards in place for each
individual form.
304 Signatures
If a form requires a signature to be obtained, that signature must be a pen and ink signature and in
the hand of the person whose signature is required or an acceptable electronic (digital) signature
in accordance with the AIPs established EBIP. Rubber or similar signature stamps are not
acceptable. Refer to the GSH for more information regarding signatures and signature authority.
If multiple forms have been combined into one form, but the information reported by the insured
is collected at different times, a signature must be obtained at the time of collection from the
insured consistent with the signature guidelines required for each form.
The AIP has the discretion of using “printed name”, “name”, or some other variation on a form
where a signature and a printed name is substantive.
June 2015
FCIC 24040
9
305 Interest Rates
Any form standards containing an interest rate for unpaid payment amounts cannot be higher
than the rates provided in the 7 CFR 457.8 sections 24 and 26.
306 Required Statements
Unless otherwise indicated, required statements pertain to all insurance policies administered
under the SRA, not only to those standards that appear in this handbook. All required statements
must appear verbatim on the AIP generated form unless otherwise noted. See Parts 5 and 6 for
applicable required statements and disclosures.
If a person refuses to acknowledge required statements, then the AIP representative should
annotate such refusal; affix the AIP Representative’s printed name and signature, the time, and
date to the form where such statement(s) have been refused.
307-400
June 2015
(Reserved)
FCIC 24040
10
PART 4 GENERAL FORM STANDARDS
401 Form Style
A. Format
Form standard item entries may be formatted as line entries, column headings, boxes, tables,
or blocks, as appropriate. Headings for form entries may be abbreviated, provided an
explanation is included in the form completion instructions. It is at the AIP’s discretion
whether the required headings are column headings or row headings.
B. Form Title
The Form Title and a Form Identification Number (alpha and/or numeric) must be on all
forms. The Form Identification Number is to be developed according to the internal
procedures of the AIP.
C. Font Size
The text for all documents should be developed with an 8-point font size when possible;
however, font size shall not be less than 6-point. This will assist the applicants/insureds in
reading documents presented to them.
D. Page Numbering
If multiple pages are required for a particular form each page must be numbered as follows:
“Page __of __”.
E. Required Statements
If a statement is on the back of the form, add “See Reverse Side for Required Statements”, or
other similar reference, on the front of the form.
402 Identification Numbers
Identification numbers include Social Security Number (SSN), Employer Identification Number
(EIN) or RMA Assigned Number (RAN).
A. Form Completion Instructions
Form completion instructions must:
(1) Provide instruction to enter the appropriate identification number;
(2) Provide instruction to enter the correct identification number type; and
(3) Provide the applicant/insured the opportunity to verify that their reported identification
number is correct.
June 2015
FCIC 24040
11
402 Identification Number (Continued)
B. Masking
Masking, also called “truncating”, results in the 9 digit identification number being displayed
as XXXXX1234, XX-XXX1234, XXX-XX-1234, or other variation on AIP generated forms
for security.
AIPs must mask the identification number on AIP generated forms containing an
identification number. This includes, but is not limited to, forms generated for such purposes
as loss adjustment and underwriting reviews. Identification number must not be masked
when reported by the person providing the identification number.
If the identification number is unmasked in order to provide the applicant/insured an
opportunity to verify whether the identification number is true and accurate, the AIP must
employ a method of protecting such number.
C. Identification Number Type on Forms
Must contain the following, check one:
□ SSN
□ EIN
□ RMA Assigned Number
AIPs may use an alternate format for allowing the identification number type provided all
identification number types are present (SSN/EIN/RAN).
403 Person Types
Form completion procedures must provide instructions to enter the specific person type, not the
SRA Appendix III entity type code. This entry is verified for accuracy during applicable RMA,
USDA oversight agencies, or AIP reviews, and at loss adjustment time. See Part 2 of the GSH
for person type descriptions and see also SRA Appendix III for applicable entity type codes.
404 Substantial Beneficial Interest Holder
For persons with a substantial beneficial interest in the insured as identified on the application:
the person type, identification number and identification number type is not required on each
individual form if it is collected on the Social Security Number and Employee Identification
Number Reporting form. See Exhibit 22.
June 2015
FCIC 24040
12
405 Agent/Loss Adjuster Code
If an AIP assigns a code for its agent or loss adjuster, that code is “Substantive”. The assigned
code number cannot be the individual’s SSN or a variation thereof. The code number is required
to be completed on the applicable form, as follows:
I.B. Agent 06/01/2015
(Agent’s Signature) (Date)
12RMA34
(Code Number)
406 State and County Name
The entry for "State and County" must be the state and county name where insurance attaches.
Form completion procedures must provide this information.
407 AIP Name and Address
AIP’s full name and address as specified in the SRA. The AIP may select item (1) or (2) to fulfill
this “substantive” requirement where required on an individual form:
(1)
Provide the AIP’s name and address with the policy or policy jacket at time of issue; or
(2)
Provide the AIP’s full name and address on all forms.
Note:
This exception does not circumvent the requirement for the Agent’s company name and
address to be provided where indicated on the form as substantive.
408 Street and/or Mailing Address
“Street and/or Mailing Address” are substantive items as indicated by the applicable form
standard. When the street and mailing addresses are different, only the mailing address is the
required entry.
409 City, State, Zip Code
“City”, “State”, “Zip Code” are substantive items as indicated by the applicable form standard
when these items or the form requires “Street and/or Mailing Address”. The AIP has discretion
of whether to add these items as independent form entries or provide instruction that the “Street
and/or Mailing address” form entry includes the “city, state, and zip code” as appropriate.
June 2015
FCIC 24040
13
410 Added County Election
Guidelines to administer this election are found in the GSH.
If AIPs elect to include this option on the application, one or both of the following statements
must appear on the application as “Substantive”:
“□ Yes □ No
□ 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.
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.
If your designated plan of insurance, level of coverage or price is not available in the added
county, coverage will be provided through the Catastrophic Risk Protection Endorsement, if the
crop is insurable in the actuarial documents for an added county.”
411 Landlord/Tenant Insuring Other’s Share
Insuring a landlord/tenant is on a crop/county/policy basis. The form must clearly state the
tenant will insure the landlord’s share or landlord will insure the tenant’s share. Form
completion instructions must provide an explanation of the landlord/tenant insuring the other’s
share and must require evidence of the non-insuring party’s approval. AIPs may use the alternate
language with the form’s completion instructions providing explanations. Guidelines are found
in the GSH.
Suggested formats (Substantive):
(1)
(2)
“Is applicant insuring the tenant’s share?”
“Yes
□
No
□”
“Is applicant insuring the landlord’s share?”
“Yes
□
No
□”; or,
“In addition to my share on this policy, I am insuring:
□
□
(3)
June 2015
My landlord’s share. I am providing a Power of Attorney or Lease Agreement as
evidence of my authority to insure their 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,
Enter statement in the Remarks section that landlord/tenant is insuring the other’s share
under the crop policy.
FCIC 24040
14
412 Price Election
When Price Election appears on the application, it must be clearly indicated if “Additional Price
or Established Price” is elected.
Price Election may be shown as “Price times Price Election Percentage”, or in aggregate. If
shown in aggregate, form completion standards must explain “Price times Price Election
Percentage”.
413 Options, Elections, or Endorsements
The policy may authorize options, elections and endorsements that require an insured to elect,
add, exclude or otherwise modify coverage. If a form is specifically developed for (or a form is
specifically modified to capture) an option, election or endorsement, it must be used by the AIP.
Otherwise, AIPs must use the following forms for an insured to elect, add, exclude or otherwise
modify coverage:
(a)
Required on or before the SCD, AIPs must use the Application or the Policy Change form.
(b)
Required on or before the ARD or PRD, AIPs must use the Policy Change form.
June 2015
FCIC 24040
15
414 Actuarial Fields
The actuarial documents and RMA processing systems include the following subfields under
Type and Practice:
(1)
Type (Substantive)
(a)
(b)
(c)
(d)
(2)
Commodity Type (Non-Substantive)
Class (Non-Substantive)
Subclass (Non-Substantive)
Intended Use (Non-Substantive)
Practice (Substantive)
(a)
(b)
(c)
(d)
Irrigation Practice (Non-Substantive)
Cropping Practice (Non-Substantive)
Organic Practice (Non-Substantive)
Interval (Non-Substantive)
AIPs may add the additional fields to the applicable forms requiring the Type/Practice
information; however, this is a non-substantive requirement. If AIPs choose to include these
on the applicable form, the Type/Practice information must be developed to reflect the
following:
TYPE
COMMODITY
TYPE
CLASS SUBCLASS
PRACTICE
INTENDED
USE
IRRIGATION
PRACTICE
CROPPING
PRACTICE
ORGANIC
PRACTICE
INTERVAL
415-500 (Reserved)
June 2015
FCIC 24040
16
PART 5 GENERAL REQUIRED STATEMENTS AND DISCLOSURES
501 RMA Privacy Act Statement – Collection of Information and Data
The Privacy Act prohibits the disclosure of protected information absent the written consent of
the individual. The Privacy Act statement is required for agents, loss adjusters and
policyholders. This statement must be included on any form the person signs and a copy
maintained by the AIP.
Protected information includes, but is not limited to, any personally identifiable information
about a policyholder, agent, or loss adjuster; and information about the policyholder’s farming
operation or insurance policy. Such information is generally acquired from the policyholder,
agent or loss adjuster, USDA, the Comprehensive Information Management System, or the
insured’s previous or current approved insurance provider or agent that is protected from
disclosure by the Privacy Act, section 502(c) of the Federal Crop Insurance Act (Act), or any
other applicable statute. This includes all hard copy or electronic information. See also, Para.
603
If the Privacy Act statement is provided as a separate document, evidence of receipt of this
statement must be shown by securing the signature of applicant/insured/agent/loss adjuster and
the date at the time of collection. This process must be completed for each document that
requires the Privacy Act statement. The AIP must be able to substantiate the statement was
provided in accordance with the Privacy Act. If the AIP can substantiate with legal sufficiency
the insured received and acknowledged these required statements by an alternative method, then
such method is acceptable. See Exhibit 3.
502 RMA Certification Statement
The Certification Statement must be included on any form that the person signs which collects
information from the person, such as the application, acreage report, etc. The certification
statement is not applicable to appraisal worksheets. See Exhibit 2.
If a form standards contain a modified certification statement, such as the Individual Conflict of
Interest Disclosure, this certification statement is not required, unless otherwise noted by the
form standards.
503 RMA Non-Discrimination Statement
It is the AIPs’ responsibility to ensure that standards, procedures, methods and instructions, as
authorized by FCIC in the sale and service of crop insurance contracts, are implemented in a
manner compliant with Title VI. The Non-discrimination Statement must be included on any
form the person signs or provided to the person on a separate form in which the person signs and
a copy maintained by the AIP. Additionally, applicable AIP marketing materials must also
include a non-discrimination statement. Refer to Exhibit 4 for the Non-Discrimination
Statements. The RMA and USDA Non-Discrimination Statement is available on the RMA
public website at:
(1)
RMA Non-Discrimination Statement: http://www.rma.usda.gov/web/nondiscrim.html
(2) Office of Assistant Secretary for Civil Rights:
http://www.usda.gov/wps/portal/usda/usdahome?navtype=FT&navid=NON_DISCRIMINA
TION.
June 2015
FCIC 24040
17
504 USDA Multiple Benefit Statement
AIPs must include the Multiple Benefit Statement on the acreage report. See Exhibit 5.
505 Native Sod (Reserved)
Reserved.
506 Conservation Compliance – First Time Farmer (Reserved)
Reserved.
507 Conditions of Acceptance Statement
The application is accepted and insurance attaches in accordance with the policy unless:
(1)
(2)
(3)
(4)
FCIC determines that, in accordance with the regulations, the risk is excessive;
Any material fact is omitted, concealed, or misrepresented in the application or in the
submission of the application;
The applicant failed to provide complete and accurate information required by the
application, or
An affirmative answer to any question appearing on the Conditions of Acceptance form.
508-600 (Reserved)
June 2015
FCIC 24040
18
PART 6 AIP REQUIRED STATEMENTS AND DISCLOSURES
601 Anti-Rebating Certification Statement
In accordance with section 508(a)(9) of the Act and the SRA, a company and its affiliates are
prohibited from providing a rebate, except as authorized in section 508(a)(9)(B). For more
information regarding rebates, contact RMA Reinsurance Services Division.
The Anti-Rebating Certification is an individual certification of the applicant/insured and the
agent required at the time liability is established. This certification is required for each crop year
for the crop or crops contained on the application associated with the policy number.
Furthermore, the agent is the agent who accepts and signs the applicable form in which liability is
established. The time liability is established is the time specified by the applicable policy, e.g., at
acreage reporting time. See Exh. 8.
602 Covenant Not to Sue Statement (Covenant)
As defined in Section 1 of the SRA, before an agent is allowed to act on behalf of an AIP with
respect to the sales or service of eligible crop insurance contracts, the AIP must obtain from such
agent the written acknowledgement referred to in Section III(a) of the SRA.
If the agent fails to sign written acknowledgement to the Covenant by the deadline, any policies
sold or serviced by such agent will be denied reinsurance by RMA. Exhibit 9 provides an
example of the Covenant for use by the AIP, or any other Covenant utilized by the AIP which
meets the standards required by Section III(a) of the SRA is acceptable.
A.
Incorporation
To the extent that an AIP has contracts with individual agents, the Covenant Not to Sue
Statement (Covenant) must be incorporated into or appended to such contracts. If written
acknowledgement was incorporated or appended to an agency contract covering multiple
agents, it does not meet the requirement of Section III(a)(2)(K) of the SRA, unless such
acknowledgement is signed individually by each agent within the agency.
The AIP is not required to certify to RMA that it has obtained written acknowledgement
from each agent. However, AIPs will be required to provide RMA a copy of such
acknowledgement for any agent upon request.
B.
Prior RY Covenant Acknowledgements
If existing Covenant acknowledgements executed in previous RYs did not have specific
references, or any other terminology that would limit its effect to the previous RY only,
such acknowledgement may be considered effective for future RYs.
However, if existing acknowledgements of the Covenant have a RY limitation, then a new
acknowledgement without the RY limitation must be executed by the agent. If an agent
executes, or has previously executed an acknowledgement of the Covenant with no date
limitation, then no other acknowledgement is needed as long as the executed
acknowledgement is provided to each AIP for which the agent acts.
June 2015
FCIC 24040
19
603 Non-Disclosure Statements (NDS)
A.
AIP Annual Certification for Affiliates/Contractors
AIPs must notify contractors and affiliates regarding the requirement that all persons
employed by or having a contract with the contractor or affiliate must signed NDS prior to
obtaining access to Protected Information. By April 1 prior to the start of the reinsurance
year, an AIP must obtain an Annual Certification from each of its contractors and affiliates
certifying the respective contractor or affiliate has obtained an NDS from each person who
has access to any Protected Information and who is employed by or has a contract with the
contractor or the affiliate.
The certification must be signed and witnessed by an officer of the affiliate or contractor.
The following statement must accompany the AIP Annual Certification to RMA:
“I hereby certify that [INSERT THE NAME OF THE AFFILIATE OR CONTRACTOR]
has reviewed its files and, as of [INSERT DATE REVIEW WAS COMPLETED], all
employees or other persons having access to Protected Information have signed a nondisclosure statement.”
B.
AIP Annual Certification to RMA
Annual Certification is required to ensure any new employee or other person having access
to Protected Information has signed and executed an NDS. The AIP must provide an
Annual Certification to RMA:
(1)
An NDS exists from all persons who have access to any Protected Information and
who are employed by or have a contract with the AIP; and
(2)
In the case of persons employed by a contractor or affiliate, has obtained a
certification from the contractor or affiliate that they have obtained an NDS from their
employees with access to Protected Information.
The following certification must be signed by an officer of the AIP:
“I hereby certify that [INSERT AIP NAME] has reviewed its files and as of [INSERT
DATE REVIEW WAS COMPLETED], all employees or other persons having access
to Protected Information have signed a non-disclosure statement and all affiliates and
contractors have certified that their employees and other persons having access to
Protected Information have signed non-disclosure statements.”
The AIP must provide this certification with the annual Plan of Operations, which is due no
later than April 1 prior to the start of the reinsurance year and sent to:
Director, Reinsurance Services Division
USDA/Risk Management Agency
1400 Independence Avenue SW
Stop 0804
Washington, DC 20250-0804
June 2015
FCIC 24040
20
603 Non-Disclosure Statements (NDS) (Continued)
B.
AIP Annual Certification to RMA (continued)
AIPs and their contractors and affiliates may use electronic versions of the NDS form
which incorporates either a digital signature or an authentication system to properly identify
the submitter. Electronic records of signed or authenticated NDS’s must be retained by the
respective AIP, contractor, or affiliate and be available for inspection. Additionally Para.
402 applies. See also Exh. 10.
C.
Individual Certification
All persons who have executed an acceptable NDS will be provided access to Protected
Information. If a person employed by or having a contract with the AIP has previously
executed an NDS with another AIP, that person must:
(1)
Either submit a copy of the original NDS to the AIP; or
(2)
Sign and submit a new NDS to the current AIP.
If a new NDS is properly executed the original NDS with the previous AIP is nullified. The
AIP must maintain copies of all such NDSs and make the documents available for
inspection.
604 Conflict of Interest (COI) Disclosure Statements
All agents, loss adjusters, employees, and affiliates must submit an executed Conflict of Interest
Disclosure Statement by the earliest applicable acreage reporting date. Any changes to a
disclosure statement previously submitted in accordance with these procedures must be submitted
within 15 days of entering a relationship requiring disclosure.
For each reinsurance year after the first disclosure, the form may contain a statement that allows
the discloser to certify that no previously disclosed information has changed from the information
contained in the previous year’s disclosure. At the AIPs discretion, the COI may include
additional information. When a revised COI is released or issued by RMA, all agents, loss
adjusters, employees, and affiliates must submit a new COI in accordance with the terms and
conditions of the newly issued statement
When a claim is filed the eligible crop insurance contracts associated with the discloser must be
identified and the AIP must ensure that the mandatory reviews are conducted. Elective reviews
may be conducted by the AIP on other business, financial, legal, or familial relationships. Use
the charts in below to evaluate the responses provided by the discloser. The chart provides a
general reference guide to determine which conflict of interest associated claims must be
reviewed by the AIP.
June 2015
FCIC 24040
21
604 Conflict of Interest (COI) Disclosure Statements (Continued)
DISCLOSER IS AN AGENT
Positive Responses to Questions in
Disclosure
Prohibited Activity
Discloser performs both agent and loss
adjustment activities, possibly for
different AIPs.
AIP must ensure the Agent does NOT perform
loss adjustment activities in same or adjoining
counties as those in which the agent performs
sales activities, regardless of whether
contracted with the AIP or another AIP.
Discloser has a share in a crop insured
under any eligible crop insurance policy
insured by the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of
the same shall not be involved in the
acceptance and verification of underwriting
data associated with any crop insurance policy
written by such person.
Mandatory
Review
Discloser has a relative with a
substantial beneficial interest in any
insurance policy insured by the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of
the same shall not be involved in the
acceptance and verification of underwriting
data associated with any crop insurance policy
written by such person.
Mandatory
Review
Discloser has power of attorney to act
on behalf of an insured or is an
authorized representative of an insured
on any eligible crop insurance policy
insured by the AIP.
The agent shall NOT perform those tasks in
the loss adjustment process on behalf of an
insured that are prohibited as specified by the
GSH and SRA.
Elective Review
Discloser has an ownership interest in a
business (excluding stock in public
corporations or entities in which the
discloser owns less than a ten percent
interest) with any insured by the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of
the same shall not be involved in the
acceptance and verification of underwriting
data associated with any crop insurance policy
written by such person.
Elective Review
Discloser has an ownership interest in a
business (excluding stock in public
corporations or entities in which the
discloser owns less than a ten percent
interest) with any insured by the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of
the same shall not be involved in the
acceptance and verification of underwriting
data associated with any crop insurance policy
written by such person.
Elective Review
June 2015
FCIC 24040
Review
Requirements
22
604 Conflict of Interest (COI) Disclosure Statements (Continued)
DISCLOSER IS AN AGENT
Positive Responses to Questions
in Disclosure
Prohibited Activity
Review
Requirements
Discloser has a rental or leasing
arrangement for land, buildings, or
equipment with any insured.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
Discloser is an owner/operator of a
business or a commission based
employee of a business, that
provides goods or services related to
farming operations (custom farming,
tractor sales, etc., but excluding
insurance services) for which the
discloser receives revenue as the
owner/operator or a direct
commission as an employee with
respect to any insured whose policy
the discloser services for the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
Discloser is an owner/operator of a
business or a commission based
employee of a business, that
provides goods or services not
related to farming operations,
excluding insurance services, for
which the discloser receives revenue
as the owner/operator or direct
commission as an employee with
respect to any insured whose policy
the discloser services for the AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
Discloser is a financial institution
employee and part of the approval
decision-making process of financial
arrangements for any insured by the
AIP.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
Discloser has an agent
compensation, barter, or financial
arrangement (excluding those
reported under question 8. above)
with any insured by the Company.
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
Discloser has a business, familial,
financial, or legal relationship that
has not been identified above with
any insured by the Company
Sales agents, owners or employees of sales
agencies, sales supervisors, or any relative of the
same shall not be involved in the acceptance and
verification of underwriting data associated with
any crop insurance policy written by such person.
Elective Review
June 2015
FCIC 24040
23
604 Conflict of Interest (COI) Disclosure Statements (Continued)
DISCLOSER IS AN ADJUSTER
Positive Responses to Questions
Prohibited Activity
in Disclosure
Review
Requirements
Discloser performs both agent and
loss adjustment activities, possibly
for different AIPs.
AIP must ensure the Adjuster does NOT perform
loss adjustment activities in same or adjoining
counties as those in which the adjuster performs
sales activities, regardless of whether contracted
with the AIP or another AIP.
Discloser has a share in a crop
insured under any eligible crop
insurance policy insured by the AIP.
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Mandatory
Review
Discloser has a relative with a
substantial beneficial interest in any
insurance policy insured by the AIP.
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Mandatory
Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Elective Review
Discloser has power of attorney to
act on behalf of an insured or is an
authorized representative of an
insured on any eligible crop
insurance policy insured by the AIP
Discloser has an ownership interest
in a business (excluding stock in
public corporations or entities in
which the discloser owns less than a
ten percent interest) with any insured
by the AIP.
Discloser has a rental or leasing
arrangement for land, buildings, or
equipment with any insured.
Discloser is an owner/operator of a
business or a commission based
employee of a business, that
provides goods or services related to
farming operations (custom farming,
tractor sales, etc., but excluding
insurance services) for which the
discloser receives revenue as the
owner/operator or a direct
commission as an employee with
respect to any insured whose policy
the discloser services for the AIP.
Discloser is a financial institution
employee and part of the approval
decision-making process of financial
arrangements for any insured by the
AIP.
Discloser has a business, familial,
financial, or legal relationship that
has not been identified above with
any insured by the AIP.
June 2015
FCIC 24040
24
604 Conflict of Interest (COI) Disclosure Statements (Continued)
DISCLOSER IS AN ADJUSTER
Positive Responses to Questions
Prohibited Activity
in Disclosure
Discloser has a relative who works
with the Federal crop insurance
program for the AIP or any of its
affiliates.
Prohibited from conducting any loss adjustment
activity on the associated crop insurance policy.
Review
Requirements
Elective Review
DISCLOSER IS AN EMPLOYEE WHO PERFORMS UNDERWRITING OR LOSS
ADJUSTMENT ACTIVITIES FOR THE AIP
Positive Responses to Questions
Review
Prohibited Activity
in Disclosure
Requirements
Discloser performs both agent and
loss adjustment activities, possibly
for different AIPs.
Discloser has a share in a crop
insured under any eligible crop
insurance policy insured by the AIP.
Discloser has a relative with a SBI in
any insurance policy insured by the
AIP
Discloser has power of attorney to
act on behalf of an insured or is an
authorized representative of an
insured on any eligible crop
insurance policy insured by the AIP.
Discloser has an ownership interest
in a business (excluding stock in
public corporations or entities in
which the discloser owns less than a
ten percent interest) with any insured
Discloser has a rental or leasing
arrangement for land, buildings, or
equipment with any insured by the
AIP.
June 2015
AIP must ensure the Employee does NOT
perform both sales and loss adjustment activities
in same or adjoining counties, regardless of
whether contracted with the AIP or another AIP.
Prohibited from involvement in the acceptance
and verification of underwriting data or
processing and verification of claim data on the
associated crop insurance policy.
Prohibited from involvement in the acceptance
and verification of underwriting data or
processing and verification of claim data on the
associated crop insurance policy.
Mandatory
Review
Mandatory
Review
Prohibited from involvement in the acceptance
and verification of underwriting data or
processing and verification of claim data on the
associated crop insurance policy.
Elective Review
Prohibited from involvement in the acceptance
and verification of underwriting data or
processing and verification of claim data on the
associated crop insurance policy.
Elective Review
Prohibited from involvement in the acceptance
and verification of underwriting data or
processing and verification of claim data on the
associated crop insurance policy.
Elective Review
FCIC 24040
25
604 Conflict of Interest (COI) Disclosure Statements (Continued)
DISCLOSER IS AN EMPLOYEE WHO PERFORMS UNDERWRITING OR LOSS
ADJUSTMENT ACTIVITIES FOR THE AIP
Positive Responses to Questions
in Disclosure
Discloser is an owner/operator of a
business or a commission based
employee of a business, that provides
goods or services related to farming
operations (custom farming, tractor
sales, etc., but excluding insurance
services) for which the discloser
receives revenue as the
owner/operator or a direct
commission as an employee with
respect to any insured whose policy
the discloser services for the AIP.
Discloser is an owner/operator of a
business or a commission based
employee of a business, that provides
goods or services not related to
farming operations, excluding
insurance services, for which the
discloser receives revenue as the
owner/operator or direct commission
as an employee with respect to any
insured whose policy the discloser
services for the AIP.
Discloser is a financial institution
employee and part of the approval
decision-making process of financial
arrangements for any insured by the
AIP.
Prohibited Activity
Review
Requirements
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
Discloser has an agent compensation,
barter, or financial arrangement
(excluding those reported under
question 8. above) with any insured
by the AIP.
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
Discloser has a business, familial,
financial, or legal relationship that
has not been identified above with
any insured by the AIP
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
Discloser has a relative who works
with the Federal crop insurance
program for the AIP or any of its
affiliates.
Prohibited from involvement in the acceptance and
verification of underwriting data or processing and
Elective Review
verification of claim data on the associated crop
insurance policy.
June 2015
FCIC 24040
26
605 Annual Controlled Business Certification
A.
General Information
Section 508(a)(10) of the Act prohibits an individual from receiving compensation for the
sale and service of a policy or plan of insurance, if the total compensation to be paid to the
individual for policies in which the individual or an immediate family member has a
substantial beneficial interest exceeds 30 percent of the total compensation for the sale and
service of all policies or plans of insurance under the Act, or a lesser percentage, if the
respective State has a lower limit for controlled business. Immediate Family Member is
defined in the GSH.
AIPs must ensure that all individuals, including subagents, receiving compensation
(including any salary commission, profit sharing, bonus, or any other direct or indirect
benefit) for the sales and service of FCIC policies or plans of insurance through the AIP or
any AIP affiliated entity have timely access to the certification form and have had a
reasonable opportunity to complete and return the form to the AIP prior to 90 days
following the annual settlement date for the reinsurance year. All certifications are to be
retained by the AIP or its affiliate and not sent to RMA.
AIPs may use electronic versions of the certification forms that incorporate either a digital
signature or an authentication system to properly identify the submitter. Electronic records
of signed or authenticated certification forms must be retained by the respective AIP and be
available for inspection.
If an AIP began collecting certification using procedures that differ from those below, the
AIP must notify Reinsurance Services Division at the address listed in Para. 605E below.
B.
Compensation More than 30 Percent –Immediate Family Policies
If the amount of compensation to which the individual is entitled under its contract with the
AIP or affiliate would result in the agent receiving more that 30 percent from immediate
family polices, the individual is in violation of section 508(a)(10). An individual in
violation cannot:
(1)
Pay back an amount necessary to be in compliance;
(2)
Defer payments to determine whether they will violate the provision; or
(3)
Take any other action to adjust the individual’s compensation owed under the contract
with the AIP or affiliate.
An individual in violation of section 508(a)(10) will be subject to disqualification and civil
fines under the procedures implementing section 515(h) of the Act, and any other
procedures approved by RMA implementing section 515(h). The gravity of the violation
by the individual will determine whether a sanction is imposed and if so, the type and
amount.
June 2015
FCIC 24040
27
605 Annual Controlled Business Certification (Continued)
C.
Individual Annual Certification to AIP or Affiliate
An individual subject to the certification requirement of the Act must submit an annual
certification to each AIP with which he or she has an affiliation or from which he or she has
received compensation; however, certification concerns the aggregate of all direct and
indirect compensation from all AIPs with which the individual may have an affiliation.
Example: An agent may write FCIC policies for three AIPs, but have family members
with substantial beneficial interests in policies written with one of the AIPs.
Such an agent would be required to answer affirmatively to receiving
compensation (including any salary, commission, profit sharing, bonus, or any
other direct or indirect benefit) for the sale or service of policies or plans of
insurance reinsured by FCIC for which the agent’s immediate family member
has a substantially beneficial interest.
D.
Salary and Compensation.
Salary compensation must not be treated differently than commission or the percentage of
compensation received from policies. Salary compensation shall be determined by:
E.
(1)
Dividing the individual’s salary by the total amount of premium written by the
individual;
(2)
Multiplying the result of (1) by the amount of total premium from the policies in
which the individual and any immediate family member(s) have a substantially
beneficial interest; and
(3)
Dividing the results of (2) by the total premium written by the individual.
Controlled Business Notification to RMA
Within 120 days following the annual settlement date for the reinsurance year, AIPs must
notify RMA, from among all individuals who have received compensation (including any
commission, profit sharing, bonus, or any other direct or indirect benefit) for the sales and
service of an FCIC policy or plan of insurance, any specific individuals who either:
June 2015
(1)
Have not certified to the AIP by properly completing and returning a signed form to
the AIP for the reinsurance year; or
(2)
Have answered affirmatively to receiving compensation (including any salary,
commission, profit sharing, bonus, or any other direct or indirect benefit), for the sale
or service of policies or plans of insurance reinsured by FCIC for which the individual
or the individual’s immediate family member have a substantial beneficial interest.
FCIC 24040
28
605 Annual Controlled Business Certification (Continued)
E.
Controlled Business Notification to RMA (continued)
This notification must be directed to:
Director, RMA/Reinsurance Services Division
1400 Independence Ave SW
Room 6741-S, Stop 0804
Washington D.C. 20250-0804
F.
Individual Controlled Business Certification
If the AIP is collecting all of the Individual Controlled Business Certification, the AIP must
certify to RMA that it has collected all forms from those individuals required to submit an
Individual Controlled Business Certification.
G. Affiliate Controlled Business Certification
An Affiliate Controlled Business Certification is required if an affiliate is responsible for
collecting the individual certifications on behalf for the AIP. The AIP is not required to
obtain a copy of the individual certifications if they have received the affiliate certification
form for those individuals. The affiliate must retain the individual certifications for which
they are certifying receipt.
June 2015
FCIC 24040
29
606-700 (Reserved)
June 2015
FCIC 24040
30
Exhibit 1
Conditions of Acceptance Statements
Condition 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 delinquent debt?
(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.
Note: For RI/VI Applications Only, remove the following statement: “The insurance contract,
which includes the accepted application, is defined in the regulation published at 7 CFR chapter IV.”
June 2015
FCIC 24040
31
Exhibit 2
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).
June 2015
FCIC 24040
32
Exhibit 3
Collection of Information and Data Statement – Privacy Act for Agents, Loss Adjusters, and
Policyholders
The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a): The
Risk Management Agency (RMA) is authorized by the Federal Crop Insurance Act (7 U.S.C. 15011524) or other Acts, and the regulations promulgated thereunder, to solicit the information requested
on documents established by RMA or by approved insurance providers (AIPs) that have been approved
by the Federal Crop Insurance Corporation (FCIC) to deliver Federal crop insurance. The information
is necessary for AIPs and RMA to operate the Federal crop insurance program, determine program
eligibility, conduct statistical analysis, and ensure program integrity. Information provided herein may
be furnished to other Federal, State, or local agencies, as required or permitted by law, law
enforcement agencies, courts or adjudicative bodies, foreign agencies, magistrate, administrative
tribunal, AIP’s contractors and cooperators, Comprehensive Information Management System (CIMS),
congressional offices, or entities under contract with RMA. For insurance agents, certain information
may also be disclosed to the public to assist interested individuals in locating agents in a particular
area. Disclosure of the information requested is voluntary. However, failure to correctly report the
requested information may result in the rejection of this document by the AIP or RMA in accordance
with the Standard Reinsurance Agreement between the AIP and FCIC, Federal regulations, or RMAapproved procedures and the denial of program eligibility or benefits derived therefrom. Also, failure
to provide true and correct information may result in civil suit or criminal prosecution and the
assessment of penalties or pursuit of other remedies.
June 2015
FCIC 24040
33
Exhibit 4
Non-Discrimination Statement for Forms and Marketing Materials
A.
Forms - Non-Discrimination Statement
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers,
employees, and applicants for employment on the bases of race, color, national origin, age,
disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs,
marital status, familial or parental status, sexual orientation, or all or part of an individual's
income is derived from any public assistance program, or protected genetic information in
employment or in any program or activity conducted or funded by the Department. (Not all
prohibited bases will apply to all programs and/or employment activities.)
To File a Program Complaint
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA
Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint
filing cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may
also write a letter containing all of the information requested in the form. Send your
completed complaint form or letter by mail to the U.S. Department of Agriculture, Director,
Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by
fax (202) 690-7442 or email at program.intake@usda.gov.
Persons with Disabilities
Individuals who are deaf, hard of hearing or have speech disabilities and wish to file either an
EEO or program complaint please contact USDA through the Federal Relay Service at (800)
877-8339 or (800) 845-6136 (in Spanish).
Persons with disabilities, who wish to file a program complaint, please see information above
on how to contact the Department by mail directly or by email. If you require alternative
means of communication for program information (e.g., Braille, large print, audiotape, etc.)
please contact USDA's TARGET Center at (202) 720-2600 (voice and
TDD).
B.
AIP Marketing Materials – Non-Discrimination Statement
“This institution is an equal opportunity provider” or “[AIP NAME] is an equal opportunity
provider. The U.S. Department of Agriculture (USDA) prohibits discrimination against its
customers, employees, and applicants for employment on the bases of race, color, national origin,
age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs,
marital status, familial or parental status, sexual orientation, or all or part of an individual's
income is derived from any public assistance program, or protected genetic information in
employment or in any program or activity conducted or funded by the Department. (Not all
prohibited bases will apply to all programs and/or employment activities).
Exception: If the literature is too small to accommodate the statement in B above, the AIP may
use, “[T]his institution is an equal opportunity provider” or “[AIP NAME] is an equal
opportunity provider.”
June 2015
FCIC 24040
34
Exhibit 5
USDA Multiple Benefit Certification Statement
I understand that obtaining multiple Federal benefits for the same loss, such as a Noninsured Crop
Disaster Assistance Program (NAP) payment(s) and a Federal crop insurance indemnity, is prohibited
by law. I certify that I have, or will disclose any other USDA benefit; including any NAP benefit,
received for this crop. Failure to disclose the receipt of multiple Federal benefits, or failure to repay
one of the multiple Federal benefits such as either the NAP benefit or the Federal crop insurance
indemnity for the same crop, may result in my being disqualified from receiving Federal crop
insurance benefits, as well as being ineligible for various programs administered by the Farm Service
Agency for up to five (5) years.
June 2015
FCIC 24040
35
Exhibit 6
Native Sod (Reserved)
Reserved.
June 2015
FCIC 24040
36
Exhibit 7
Conservation Compliance- First Time Farmer (Reserved)
Reserved.
June 2015
FCIC 24040
37
Exhibit 8
Anti-Rebating Certification
The AIP has the discretion of developing either a combined certification for the applicant/insured and
the agent or one form for the applicant/insured and one for the agent. The standards below reflect a
combined form. See paragraph 408 for more information regarding this certification.
General Information
A
B
C
D
E
“Applicant/Insured Name”
“Policy Number”
“Agent’s Name”
“Agent Code Number”
“Crop Year”
Substantive
Substantive
Substantive
Substantive
Substantive
Anti-Rebating Statement(s)
A
B
Applicant/Insured
Statement
“I certify, for the crop year indicated, that I have not directly
or indirectly received, accepted, or been paid, offered,
promised, or given any benefit, including money, goods, or
services for which payment is usually made, rebate, discount,
abatement, credit, or reduction of premium, or any other
valuable consideration, as an inducement to procure insurance
or in exchange for purchasing this insurance policy after it has
been procured. I understand that this prohibition does not
include payment of administrative fees, performance based
discounts, and any other payment approved by FCIC that are Substantive
authorized under sections 508(a)(9)(B) and 508(d)(3) of the
Federal Crop Insurance Act (Act) (7 U.S.C. §§ 1508(a)(9)(B)
and 1508(d)(3)). I understand that a false certification or
failure to completely and accurately report any information on
this form may subject me, and any person with a substantial
beneficial interest in me, to sanctions, including but not limited
to, criminal and civil penalties and administrative sanctions in
accordance with section 515(h) of the Act (7 U.S.C. §1515(h))
and all other applicable federal statutes.”
Agent Statement
“I certify, for the crop year indicated, that I have neither
offered nor promised, directly or indirectly, any benefit,
including money, goods, or services for which payment is
usually made, rebate, discount, credit, reduction of premium,
or any other valuable consideration to this person either as an
inducement to procure insurance or in exchange for obtaining
insurance after it has been procured. I understand that this
prohibition does not include payment of administrative fees,
performance based discounts, and any other payment approved
Substantive
by FCIC that are authorized under sections 508(a)(9)(B) and
508(d)(3) of the Federal Crop Insurance Act (Act) (7 U.S.C.
§§ 1508(a)(9)(B) and 1508(d)(3)). I understand that a false
certification or failure to completely and accurately report any
violation may subject me, and all agencies/companies I
represent, to sanctions, including but not limited, to criminal
and civil penalties and administrative sanctions in accordance
with section 515(h) of the Act (7 USC §1515(h)) and all other
applicable federal statutes.”
June 2015
FCIC 24040
38
Exhibit 8
Anti-Rebating Certification (Continued)
Required Signature
"Applicant/Insured’s Printed Name, Signature and Date”
Substantive
“Agent’s Printed Name, Signature, Code Number and Date”
Required Statements
A Privacy Act Statement
Substantive
A
B
B
Nondiscrimination Policy Statement
June 2015
FCIC 24040
Exhibit 3
Substantive
Exhibit 4
Substantive
39
Exhibit 9
Covenant Not to Sue
“Section III(a)(2)(K) of the Standard Reinsurance Agreement (“SRA”) obligates us, [INSERT
COMPANY NAME], to covenant not to sue the Federal Crop Insurance Corporation, Risk
Management Agency, United States Department of Agriculture, or any officer, agent, or director
thereof (collectively, “FCIC”) in any judicial or administrative proceeding, or not to assist any third
party that has instituted or filed any such proceeding, challenging the legality of the terms and
conditions of the SRA Section III(a). Section III(a)(2)(K) also obligates us [Insert name of the
Company] to obtain the following acknowledgement from you.
I agree to be an am bound by the above-stated covenant not to sue given to FCIC by you [INSERT
COMPANY NAME] regarding the terms and conditions of Section III(a).”
June 2015
FCIC 24040
40
Exhibit 10
Approved Insurance Provider Non-Disclosure Statement
1
General Information
“[INSERT COMPANY NAME] hereby agrees that it shall keep private and not
publish, use or disclose to any individual or entity, either directly or indirectly, any
Protected Information, except that it may:
(1) Use such information as necessary to perform its duties under the Standard
Reinsurance Agreement, and in accordance with applicable procedures issued by
the Risk Management Agency or the Federal Crop Insurance Corporation;
A
(2) Disclose, or provide authorization to receive, such Protected Information only to
its affiliates, employees or contractors who need such information in the
performance of their duties and who have signed an Individual Non-Disclosure
Statement or who are employed by an entity that has certified that its employees
have signed Individual Non-Disclosure Statements; and
Substantive
(3) Disclose Protected Information pursuant to a subpoena, court order, statute, law,
rule, regulation or other similar requirement (a “Legal Requirement”). Prompt
notice of such Legal Requirement shall be provided to the affected policyholders
prior to its disclosure so they may seek an appropriate protective order or other
appropriate remedy or waive compliance with the provisions of this Agreement.
B
[INSERT COMPANY NAME] further agrees that it shall keep secure all electronic
and hard copy Protected Information.
Substantive
C
[INSERT COMPANY NAME] agrees that the obligation to secure and not disclose
any Protected Information shall continue in perpetuity. However, when the period
during which records are required to be retained under the Standard Reinsurance
Agreement has ended, Protected Information may be properly disposed of and
destroyed.
Substantive
D
[INSERT COMPANY NAME] certifies that it shall adhere to all security policies and
rules provided by RMA in handling USDA information and systems.
Substantive
E
F
G
[INSERT COMPANY NAME] certifies that it shall obtain from its affiliates,
employees and contractors who are to receive any Protected Information from any
source, including from policyholders, a properly executed Individual Non-Disclosure
Statement or a certification from its contractors or affiliates that such contractors and
affiliates have obtained an Individual Non-Disclosure Statement from all persons who
will have access to any protected information and who are employed by or have a
contract with the contractor or the affiliate.
[INSERT COMPANY NAME] understands that violation of this agreement may
result in civil and criminal penalties under the Privacy Act or section 1770c of the
Food Security Act of 1985 (7 U.S.C. § 2276c).”
Include the following definitions.
“For the purposes of this document:”
“Protected Information means…”
“Personally Identifiable Information means…”
“RMA means…
“USDA means…”
June 2015
FCIC 24040
Note: See GSH for
applicable definitions
Substantive
Substantive
Substantive
41
Exhibit 10
Approved Insurance Provider Non-Disclosure Statement (Continued)
2
Required Statement
A
“By having its authorized representative sign below, [INSERT COMPANY NAME]
acknowledges that it will adhere to all requirements for non-disclosure contained
herein.”
3
Required Signature
A
“AIP Officer Printed Name, Signature and Date”
Substantive
B
“AIP Officer’s Title”
Substantive
June 2015
FCIC 24040
Substantive
42
Exhibit 11
Individual Non-Disclosure Statement
1
General Information
“I hereby agree that I shall keep private and not publish, use or disclose to any other
individual or entity, either directly or indirectly, Protected Information, except that I
may:
(1) Make use of such information to the extent necessary in the performance of my
duties, as required under the Standard Reinsurance Agreement, and in
accordance with applicable procedures issued by the Risk Management Agency;
A
(2) Disclose Protected Information only to employees or contractors of the approved
insurance provider or its affiliates authorized to receive such information, and
who have signed an Individual Non-Disclosure Statement; and
Substantive
(3) Disclose Protected Information pursuant to a subpoena, court order, statute, law,
rule, regulation or other similar requirement (a “Legal Requirement”). Prompt
notice of such Legal Requirement shall be provided to the affected policyholders
prior to its disclosure so they may seek an appropriate protective order or other
appropriate remedy or waive compliance with the provisions of this Agreement.”
B
C
D
E
F
2
“I hereby agree that I shall keep secure all electronic and hard copy Protected
Information and not provide access to any person not expressly authorized by the
approved insurance provider or its affiliate to receive such information.”
“I agree that my obligation to secure and not disclose any Protected Information shall
continue in perpetuity, which includes the time I am employed or under contract with
an approved insurance provider and after I leave such employment or are no longer
under contract. I understand that I may fulfill this obligation by properly destroying
Protected Information for which retention requirements have ended.”
“I certify that I will adhere to all security policies and rules provided by RMA in
handling USDA information and systems.”
“I understand that violation of this agreement may result in civil and criminal
penalties under the Privacy Act or section 1770(c) of the Food Security Act of 1985
(7 U.S.C. § 2276c).”
Include the following definitions.
“For the purposes of this document:”
“Protected Information means…”
“Personally Identifiable Information means…”
“RMA means…
“USDA means…”
See GSH for applicable
definitions
Substantive
Substantive
Substantive
Substantive
Substantive
Required Statement
A Privacy Act
3 Required Signature
A “Individual’s Printed Name and Signature and Date”
Exhibit 3
Substantive
Substantive
B
“Individual’s Title or Position”
Substantive
C
“Name of affiliate or contractor, if applicable”
Substantive
June 2015
FCIC 24040
43
Exhibit 12
Conflict of Interest
1
General Information
A “Name and address of the discloser”
B “Identification Number of the discloser”
Substantive
Substantive
“Name and address of the approved insurance provider to which you are providing the
disclosure statement, all Federal crop insurance servicing activities conducted on behalf of
the Approved Insurance Provider, or any other approved insurance provider. For example:
C □ Policy Sales
□ Loss Adjustment
□ Other (specify activity)”
Substantive
Create a block for the following questions, include a Yes � No � option at the end of each
question with instruction to check one. At the AIPs discretion, this form may include
additional information.
Yes
No
Do you have a share in a crop insured under any eligible crop
(1)
□
□ insurance contract insured by the AIP?
Do any of your relatives have a substantial beneficial interest in any
(2)
□
□ eligible crop insurance contract insured by the AIP?
Do you have a power of attorney authorizing you to act as attorneyin-fact or are you an authorized representative of a policyholder
(3)
□
□ with respect to any eligible crop insurance contract insured by the
AIP?
Do you have an ownership interest in a business (excluding stock in
(4)
□
□ public corporations or entities in which you own less than a ten
percent interest) with any policyholder insured by the AIP?
Do you have a rental or leasing arrangement for land, buildings, or
(5)
□
□ equipment with any policyholder insured by the AIP?
Are you an owner/operator of a business or a commissioned based
employee that provides goods or services related to farming
Substantive
D
operations (custom farming, tractor sales, etc., but excluding
(6)
□
□ insurance services) for which you receive revenue as the
owner/operator or a direct commission as an employee with respect
to any policyholder insured by the AIP?
Are you an owner/operator of a business or a commissioned based
employee that provides goods or services not related to farming
(7)
□
□ operations (excluding insurance services) for which you receive
revenue as the owner/operator or a direct commission as an
employee with respect to any policyholder insured by the AIP?
Are you a financial institution employee and part of the approval
(8)
□
□ decision-making process of financial arrangements for any
policyholder insured by the AIP?
Do you have an agent compensation, barter, or financial
(9)
□
□ arrangement (excluding those reported under question 8. above)
with any policyholder insured by the AIP?
Do you have a business, familial, financial, or legal relationship that
(10)
□
□ has not been identified above with any policyholder insured by the
AIP?
Do you have a relative who works with the Federal crop insurance
(11)
□
□ program, for the AIP, or any of its affiliates?
June 2015
FCIC 24040
44
Exhibit 12
Conflict of Interest (Continued)
2
Required Statements
A
“I, [INSERT DISCLOSER NAME] have been advised and agree to abide by the applicable
conflict of interest rules of the Standard Reinsurance Agreement and its Appendices, and all
applicable policies, and procedures.”
Substantive
B
If a renewal COI the AIP may create a check box with the following statement: “No
previously disclosed information has changed from the information contained in the 20XX
disclosure”
Substantive
C
Privacy Act Statement
Substantive
D
“I certify that to the best of my knowledge all information provided is true and accurate,
and that any false or inaccurate information may result in administrative, civil, and criminal
sanctions under 18 U.S.C. §§ 1006 and 1014, 7 U.S.C. § 1506, 31 U.S.C. §§ 3729 and 3730
and any other applicable federal statutes or regulations.”
Substantive
E
Nondiscrimination Policy Statement
Substantive
3
Required Signature
A
"Discloser’s Printed Name, Signature and Date”
June 2015
Exhibit 3
Exhibit 4
FCIC 24040
Substantive
45
Exhibit 13
Individual Controlled Business Certification
This form utilized by the AIP must at a minimum include the following.
1
General Information
A
“Individual’s Name”
Substantive
B
“Individual’s Title or Position”
Substantive
C
“Identification Number”
Substantive
2
A
B
C
Certification Statement
“For the [Insert the applicable reinsurance year] reinsurance year, beginning July 1,
20XX and ended June 30, 20XX.”
“This certification is required for all individuals (including subagents) who receive
compensation (including any salary, commission, profit sharing, bonus, or any other
direct or indirect benefit) for the sale of policies or plans of insurance reinsured by
FCIC.”
Include the following definition.
Note: See GSH for
applicable definitions
“Immediate Family means…”
“Please certify to the following as it applies to you.”
□
D
□
“I did not receive compensation (including any salary, commission, profit
sharing, bonus, or any other direct or indirect benefit), for the sale or service of
policies or plans of insurance reinsured by FCIC for which I or an immediate
family member (as defined) have a substantial beneficial interest.”
Substantive
Substantive
Substantive
Substantive
“I did receive compensation (including any salary, commission, profit sharing,
bonus, or any other direct or indirect benefit), for the sale or service of policies
or plans of insurance reinsured by FCIC for which I or an immediate family
member (as defined) have a substantial beneficial interest.”
“If you did receive compensation (including any salary, commission, profit sharing,
bonus, or any other direct or indirect benefit), for the sale or service of policies or
plans of insurance reinsured by FCIC for which you or your immediate family
member have a substantially beneficial interest, please certify to the following as it
applies to you:”
E
□
“The total amount of compensation (including any salary, commission, profit
sharing, bonus, or any other direct or indirect benefit), for the sale or service of
policies or plans of insurance reinsured by FCIC for which I or an immediate
family member (as defined) have a substantial beneficial interest, does not
exceed 30 percent of the total compensation I have received for the sale or
service of all FCIC policies or plans of insurance nor exceeds any applicable
State specific limitation.”
□
“The total amount of compensation (including any salary, commission, profit
sharing, bonus, or any other direct or indirect benefit), for the sale or service of
policies or plans of insurance reinsured by FCIC for which I or an immediate
family member (as defined) have a substantial beneficial interest, does exceed
30 percent of the total compensation I have received for the sale or service of all
FCIC policies or plans of insurance or exceeds any applicable State specific
limitation.”
June 2015
FCIC 24040
Substantive
46
Exhibit 13
Individual Controlled Business Certification (Continued)
3
Required Statements
B
“I acknowledge that failure to timely provide the required certification, certification I
am not in compliance with the requirements of this paragraph, or certification I am in
compliance when I am not may result in disqualification and civil fines under section
515(h) of the Federal Crop Insurance Act.”
Privacy Act Statement
Exhibit 3
C
Nondiscrimination Policy Statement
A
4
A
Exhibit 4
Substantive
Substantive
Substantive
Required Signature
"Individual’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
47
Exhibit 14
Affiliate Controlled Business Certification
The AIP utilizing this form must at a minimum include the following.
1
General Information
A
“Affiliate’s Name”
Substantive
B
“Officer or Owner’s Title or Position”
Substantive
2
Certification Statement
A
“For the [INSERT THE APPLICABLE REINSURANCE YEAR] reinsurance year,
beginning July 1, 20XX and ended June 30, 20XX.”
Substantive
B
“The officer or owner of the affiliate who affixes their signature to this certification has
the authority to sign on behalf of the affiliate, and has been designated by the [INSERT
THE NAME OF THE AIP] to receive all certifications required under section
508(a)(10(C) of the Federal Crop Insurance Act (Act).
Substantive
“I hereby certify that one of the following is true and accurate:”
□
“One or more individuals are not in compliance with the requirements of section
508(a)(10)(B) of the Act because:
C
□
D
3
All individuals (including subagents), who received, directly, or indirectly, any
compensation through the affiliate for the service or sale of any eligible crop
insurance policy/contract in the above reference reinsurance year, have submitted
certifications and all individuals certified that the total amount of compensation
they received did not exceed the amount allowed under section 508(a)(10)(B) of
the Act; ort.”
The individual did not submit an “Individual Controlled Business
Certification”;
The individual certified the total amount of compensation exceeded the
amount allowed under section 508(a)(10)(B) of the Act; or
The affiliate has discovered the individual incorrectly certified to being in
compliance with the compensation limitation under section 508(a)(10)(B)
of the Act.”
“If the affiliate has certified that one or more individuals are not in compliance with the
requirement of section 508(a)(10)(B) of the Act, a list of all individuals not in
compliance, separated in to each of the 3 categories specified above must be provided to
[INSERT THE NAME OF THE AIP] no later than [INSERT DEADLINE TO BE
ESTABLISHED BY THE AIP].”
Substantive
Substantive
Required Signature
A
"Affiliate Officer’s Printed Name, Signature and Date”
Substantive
B
“Affiliate Officer’s Title
Substantive
June 2015
FCIC 24040
48
Exhibit 15
Application
The Application is used to request insurance and must contain all of the information required by the
policy. If the required information is not contained on the application, the application is not acceptable
and insurance will not be provided. The standards below represent all Application elements for
standards identified in the CIH and GSH. The AIP may use all terms for one Application type or only
those standards that are applicable for the applicable policy (e.g., multiple Application types). A new
Application or Policy Change is required to change coverage level, prices etc. See GSH for further
information.
1
Applicant Information
A
“Applicant’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
“Applicant's Authorized Representative”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Applicant's Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
“Person Type”
Substantive
Substantive
“Spouse’s Name”
Substantive
“Spouse’s Identification Number”
Substantive
“Is applicant at least 18 years old? Yes □ No □”
“Landlord/Tenant insuring other’s share”
Substantive
M
N
2
A
B
C
D
See Para. 411
Substantive
Crop Information
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
Substantive
Substantive
Substantive
Substantive
Note: Substitute “Productivity Factor” for
RI/VI applications. AIPs may include the
applicable term for the appropriate plan of
insurance.
E
“Percentage Price Election, Projected
Price, Amount of Insurance, or
Protection Factor”
F
G
H
I
“Coverage Level”
“Practice”
“Type”
“Plan of Insurance”
J
“Added County Election”
See Para. 410
K
“Designated County” [for added county election only]
See Para. 410
L
M
N
“Grid ID”
“Index Interval”
“Percent of Value
Note: Substantive for
RI/VI Applications only.
June 2015
Note: Substantive, if coverage level varies
by practice/type
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
49
Exhibit 15
Application (Continued)
3
Other Information
A “Name of Previous AIP (if any)”
B “Policy Number under Previous AIP (if any)”
“List all person(s) 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.”
C
Required Information: (Title and Items 1-6 are
Substantive)
1.
2.
3.
4.
5.
6.
Name
Address
Telephone number
Identification Number
Identification Number Type
Person Type
“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
D
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.”
4
A
B
C
D
5
Required Statements
Conditions of Acceptance Statements
Certification Statement
Privacy Act Statement
Nondiscrimination Policy Statement
Substantive
Substantive
Note: Include a note
regarding additional space
if needed to complete lists,
e.g., (See reverse side for
additional space)
Substantive
Note: Allow space for the
applicant to list all
person(s) designated to
sign crop insurance
documents on the
applicant’s behalf.
NonSubstantive
Exhibit 1; See 3C above
Exhibit 2
Exhibit 3
Exhibit 4
Substantive
Substantive
Substantive
Substantive
Required Signatures
A "Applicant/Insured’s Printed Name, Signature and Date”
B “Agent’s Printed Name, Signature, Code Number and Date”
June 2015
FCIC 24040
Substantive
Substantive
50
Exhibit 16
Supplemental Coverage Option Endorsement
Insured’s who wish to insure under the Supplemental Coverage Option (SCO) Endorsement may
amend their policy by signing and submitting the SCO Endorsement Application, developed according
to these standards on or before the SCD for the first crop year the insured wishes to elect the
Endorsement.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
2
A
B
C
D
E
F
G
3
“Underlying Policy Number”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
Substantive
Crop Information
“County Name
“Crop(s)”
“Crop Year”
“Underlying Plan of Insurance”
“Coverage Level”
“SCO Plan of Insurance”
“ARC Coverage □ Yes □ No”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Terms and Conditions
“In addition to Section 3B(2) of the Basic Provisions, I hereby elect this Supplemental
Coverage Option Endorsement, and by this election I understand:
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
(1)
purchase this Endorsement with the same Approved Insurance Provider as my
Common Crop Insurance Policy.
A
I may elect coverage under this Endorsement and the Farm Service Agency’s
(2) Agriculture Risk Coverage Program, but the same acreage of the crop cannot be
covered under both programs.
I may elect coverage under this Endorsement and Stacked Income Protection Plan
(3)
for the upland cotton, but the same acreage cannot be insured under both.
Substantive
If at any time my Common Crop Insurance Policy for the crop is cancelled or
(4) terminated, coverage under this endorsement is automatically cancelled or
terminated.
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
(5)
date or my coverage is otherwise canceled or terminated under the terms of my
policy.
(6)
June 2015
Separate Administrative Fees will be assessed for each crop insured under this
Endorsement.”
FCIC 24040
51
Exhibit 16
Supplemental Coverage Option Endorsement (Continued)
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signature
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
52
Exhibit 17
STAX Application
Insured’s who wish to insure under the STAX Plan of Insurance must sign and submit the STAX
Application, developed according to these standards on or before the SCD for the first crop year the
insured wishes to elect STAX.
1
Applicant Information
A
“Applicant’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
“Applicant's Authorized Representative”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Applicant's Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
“Person Type”
Substantive
Substantive
“Spouse’s Name”
Substantive
“Spouse’s Identification Number”
Substantive
“Is applicant at least 18 years old? Yes □ No □”
Substantive
M
N
2
A
B
C
E
F
G
H
I
J
K
L
“Landlord/Tenant insuring other’s share”
See Para. 411
Substantive
Crop Information
“Crop”
“Effective Crop Year”
“State and County”
“Companion Policy Plan of Insurance, if applicable”
“Options, Elections, or Endorsements”
“Coverage Range”
“Practice”
Note: Substantive if coverage varies
by practice/type.
“Type”
“Area Loss Trigger
“STAX Plan of Insurance”
“STAX Protection Factor”
M
“Added County Election”
See Para. 410
N
“Designated County” [for added county election only]
See Para. 410
O
“SCO Coverage □ Yes □ No
P
“If yes, identify by APH Database whether SCO or STAX applies. If land is added to this
operation after the Sales Closing Date and reported by the Acreage Reporting Date, such
acreage will be covered by □ SCO □ STAX.”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
NonSubstantive
Substantive/
NonSubstantive
Substantive
Substantive
53
Exhibit 17
STAX Application (Continued)
3
Other Information
A “Name of Previous AIP, if any
Substantive
B “Policy Number under Previous AIP, if any”
Substantive
“List all person(s) 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.”
Required Information: (Title and Items 1-6 are Substantive)
C
4
1.
2.
3.
4.
5.
6.
Name
Address
Telephone number
Identification Number
Identification Number Type
Person Type
Note: Include a note
regarding additional
space if needed to
complete lists, e.g.,
(See reverse side for
additional space)
Substantive
Terms and Conditions
“I may not elect coverage under this plan of insurance on the same acres I elect coverage
for the Supplemental Coverage Option Endorsement (SCO) if I participate in the SCO.
A I understand that by signing this application, the coverage under this plan of insurance it
Substantive
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.”
5
Required Statements
A
“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.”
B
Conditions of Acceptance Statements
C
Certification Statement
Exhibit 1; See 3C
above
Exhibit 2
D
Privacy Act Statement
Exhibit 3
Substantive
E
Nondiscrimination Policy Statement
Exhibit 4
Substantive
6
Required Signature
A
“Applicant’s/Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
Note: Allow space
for the applicant to
list all person(s)
designated to sign
crop insurance
documents on the
applicant’s behalf.
NonSubstantive
Substantive
Substantive
54
Exhibit 18
BFR Application
A BFR Application is completed when an individual initially applies for BFR status; chooses to
modify the crop year(s) of insurable interest exceptions; or to correct a previously submitted BFR
Application. The BFR Application is required to be submitted by the applicable SCD. BFR status will
not apply to any crops with a SCD prior to completion of the BFR Application.
1
A
B
C
D
E
F
G
H
2
Applicant Information
“Applicant’s Name”
Substantive
“Applicant’s Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Applicant's Telephone Number”
Substantive
“Crop Year”
Substantive
“Applicant’s Identification Number”
Substantive
“Applicant’s Identification Number Type”
Substantive
Beginning Farmer/Rancher Certification
“I have produced the following crop(s) and/or livestock in the identified
State(s)/County(ies) during the time periods provided:”
DATES PRODUCING ANY CROP OR LIVESTOCK
FROM
(MM/YY)
TO
(MM/YY)
TYPE OF
CROP(S)/LIVESTOCK
STATE/
COUNTY
CROP
YEAR
USDA PROGRAM*
A
Substantive
* Identify any USDA Agency/Program that you participated in for the crops/livestock”
Note: More spaces are authorized to allow multiple States and Counties and time periods
of producing crop(s) or livestock. AIPs must assist the applicant in identifying appropriate
crop year for the dates producing the crop/livestock.
“I request the following Beginning Farmer/Rancher authorized exclusions from
consideration as crop years producing crop(s) or livestock. I certify that I was:”
TYPE OF EXCLUSION
B
DATES OF EXCLUSION
TO
FROM
(MM/YY)
(MM/YY)
CROP YEAR(S)
Under Age 18
Active Military
College
Substantive
Note: More spaces are authorized to allow multiple time periods of post-secondary
studies or active duty in the U.S. Military. The spouse of an active duty military
individual may exclude such time and include dates of exclusion in the active military type
of exclusion above for individual person types. A BFR must only complete the dates for
exclusion when the person is requesting previous crop/livestock insurable interest to be
excluded.
June 2015
FCIC 24040
55
Exhibit 18
BFR Application (Continued)
2
Beginning Farmer/Rancher Certification (continued)
“I am/am not (circle one) requesting to use the production history for a farm/ranch for which I
was involved in the decision making or the physical activities necessary to produce the crop
or livestock on the farm.
Substantive
C
If I have elected to use the production history, I will identify the applicable crop years that I
qualify to use the production history, whose production history will be used and the
Farm/Tract and Field number of the acreage for the APH information being transferred.”
3
Additional Information
To be completed by the AIP “Eligible Number of Crop Years the BFR applicant qualifies to
receive BFR benefits_____, this number includes the crop year of BFR Application.”
CROP YEARS
CROP/LIVESTOCK
PRODUCED
NUMBER OF YEAR
PRODUCING
CROP/LIVESTOCK
CROP
YEARS
EXCLUDED
A
NUMBER OF
YEARS
EXCLUDED
NUMBER OF
YEARS WHEN
DETERMINING
BFR
Substantive
Total Years
More spaces are authorized to allow multiple States and Counties and time periods of
producing crop(s) or livestock and multiple time periods of exclusion due to post-secondary
studies or active duty in the U.S. Military.
B
4
A
B
“Comments”
Note: Allow space for comments to be
written on the form.
Substantive
Required Statements
“As provided by me on this form, I certify that I have not had an interest in any crop(s) or
livestock for more than 5 crop years, nationwide, excluding time periods that I was under the
age of 18, in post-secondary studies or serving in active military service. I understand that an
interest in crops or livestock includes an interest:
(1) as an individual;
(2) as an interest holder of at least 10 percent interest in another person; and/or
(3) of any person(s) with an interest of at least 10 percent in me.
I understand that any inaccurate certification or BFR benefits beyond 5 crop years will result
in recalculation of my yield guarantees, administrative fee, premiums and any applicable loss
payments.”
“I understand that I must only complete one application for BFR; no amendment is necessary
unless I choose to cancel the benefits, correct a previously submitted form or amend my
exceptions for consideration. I also understand that I must provide the application for BFR to
any other AIPs that I may have a policy with in the current or subsequent years.
I understand that if at any time following this application, any changes are made to the
insured or substantial beneficial interest holder(s) to the policy, it may affect my eligibility
for Beginning Farmer/Rancher benefits.
Substantive
Substantive
I understand that if my policy has multiple substantial beneficial interest holders or is insuring
a landlord/tenant’s share, all must qualify as Beginning Farmer/Ranchers for benefits to
apply.”
June 2015
FCIC 24040
56
Exhibit 18
BFR Application (Continued)
4
C
D
E
F
5
A
B
C
Additional Information (continued)
“New □, Amended Application □, or Cancellation □.”
Certification Statement
Privacy Act Statement
Exhibit 2
Exhibit 3
Substantive
Nondiscrimination Policy Statement
Exhibit 4
Substantive
Substantive
Substantive
Other Information and Required Signatures
“Applicant’s Printed Name, Signature, and Date
“Approved Insurance Provider’s (AIP) Name
Substantive
AIP Representative’s Name, Signature, and Date
Substantive
June 2015
FCIC 24040
Substantive
57
Exhibit 19
Policy Cancellation
The Policy Cancellation is to be used if and when the insured decides to cancel insurance coverage and
is not transferring coverage to another AIP.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
2
A
B
C
D
E
3
“Insured’s Authorized Representative”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
“Person Type”
Substantive
Substantive
“Spouse’s Name”
Substantive
“Spouse’s Identification Number”
Substantive
Crop Information
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
“Plan of Insurance”
Substantive
Substantive
Substantive
Substantive
Substantive
Cancellation Information
A
“I hereby request cancellation of my crop insurance policy
for the crop(s) and crop year shown on this cancellation. 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.”
4
Required Statements
Note: This statement
must be placed within
a box above the
insured’s signature
line and date.
Substantive
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signature
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“AIP Authorized Representative’s Printed Name, Signature, and Date”
Substantive
June 2015
FCIC 24040
58
Exhibit 20
Policy Transfer/Application
This Policy Transfer and Application must be designed and/or have explicit form completion
instructions 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 the application information to appear in
duplicate form with the duplicate copy provided to the ceding AIP.
1
Applicant Information
A
“Applicant’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
“Applicant's Authorized Representative”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Applicant's Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
“Person Type”
Substantive
Substantive
“Spouse’s Name”
Substantive
“Spouse’s Identification Number”
Substantive
“Is applicant at least 18 years old? Yes □ No □”
“Landlord/Tenant insuring other’s share”
See Para. 411
Substantive
M
N
2
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Substantive
Crop Information
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
Substantive
Substantive
Substantive
Substantive
“Percentage Price Election, Projected Price,
Amount of Insurance, or Protection Factor”
“Coverage Level”
“Practice”
“Type”
“Plan of Insurance”
“Added County Election”
Note: Substitute “Productivity Factor”
for RI/VI applications. AIPs may
include the applicable term for the
appropriate plan of insurance.
Note: Substantive, if coverage varies by
practice/type.
See Para. 410
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Designated County” [for added county election only]
Substantive
“Grid ID”
“Index Interval”
“Percent of Value
Substantive/
NonSubstantive
June 2015
Note: Substantive for RI/VI
Policy/Transfer Applications only.
FCIC 24040
59
Exhibit 20
Policy Transfer/Application (Continued)
3
Required Language for Request
“Part I
A
B
C
4
A
B
C
5
I hereby request cancellation of my insurance policy with [INSERT CEDING AIP]
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.”
“Crop(s)” to be canceled and transferred
“Crop Year” of crops being canceled and transferred
Substantive
Substantive
Substantive
Required Language to Authorize and Signatures
“I hereby authorize and direct the [INSERT CEDING AIP 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 delinquent debt had this
transfer not occurred, no coverage can be provided by the [ASSUMING AIP].”
Substantive
“Insured’s Printed Name, Signature and Date”
“Policy Number”
Substantive
Substantive
Required Language to Provide Insurance and Signatures
“Part II
A
B
C
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.”
Substantive
Substantive
Substantive
A
“Name of Assuming Agent”
“Assuming Agent’s Address, City, State and Zip Code”
“Signature of Approved Insurance Provider Representative Authorized to Accept
Applications”
“Date of Acceptance by Assuming Approved Insurance Provider”
“Assuming Approved Insurance Provider and Policy Issuing Company Code”
Required Statements
Certification Statement
Exhibit 2
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
D
E
F
6
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
60
Exhibit 21
Policy Change
This form is to be used to make changes to the insurance policy without creating a new application.
Some changes can be made after the sales closing date, such as changing an insured’s physical address.
Refer to the GSH.
1
Applicant Information
A
“Insured’s Name”
B
C
D
E
F
G
“Insured's Authorized Representative”
“State and County”
“Policy Number”
“Identification Number”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Identification Number Type”
“Person Type”
Substantive
“List all person(s) 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.”
H
Required Information: (Title and
Items 1-6 are Substantive)
1. Name
2. Address
3. Telephone number
4. Identification Number
5. Identification Number Type
6. Person Type
“Added County Election”
“Designated County” [for added county election only]
I
J
2
Changes to Insurance Coverage
A
“Change Insurance ”
B
“Effective Crop Year”
C
“Crop”
D
E
G
“Practice”
“Type”
“Percentage Price Election,
Projected Price, Amount of
Insurance, or Protection Factor”
“Coverage Level”
H
“Plan of Insurance”
F
Note: Include a note regarding additional space if
needed to complete lists, e.g., (See reverse side for
additional space)
June 2015
See Para. 410
See Para. 410
Note: Form completion procedures must provide
instruct to check this box when appropriate.
Substantive
Substantive
Substantive
Substantive
Substantive
Note: For identification purposes only, a crop
cannot be added using a Policy Change.
Note: Substantive, if coverage varies by
practice/type.
Note: Substitute “Productivity Factor” for RI/VI
applications. AIPs may include the applicable term
for the appropriate plan of insurance.
Substantive
Substantive
Substantive
Substantive
Substantive
Note: Plan of insurance cannot be changed using a
Policy Change between different plans of insurance
that have different Basic Provisions.
FCIC 24040
Substantive
61
Exhibit 21
Policy Change (Continued)
2
I
J
K
L
3
Changes to Insurance Coverage (continued)
“Options, Elections, or
Endorsements”
“Grid ID”
“Index Interval”
“Percent of Value
See Para. 413.
Substantive
Note: Substantive for the
RI/VI Policy Change only.
Substantive/
NonSubstantive
Note: Form completion procedures must
provide instruct to check this box when
appropriate.
Substantive
Cancellations
A “Cancel Insurance ”
B “Effective Crop Year”
C “Crop”
Substantive
Substantive
D “Options, Elections, or Endorsements”
E
F
Note: The AIP must meet the standards
that are set forth in the policies, options
and endorsements as issued by RMA. See
Para. 413.
“Practice”
“Type”
Substantive
Substantive
Substantive
Note: Create item entries for Reason of Cancellation,
similar to the example below. Provide form and
completion procedures which instruct that the reason for
cancellation must be explained in the remarks section of the
form. The form must explain the effective crop year.
G “Reasons for Cancellation”
June 2015
(Check One)
(Explain in Remarks)
□ Insured's Request
□ Mutual Consent
□ Death,
Incompetence, or
Dissolution
□ Other
FCIC 24040
Substantive
62
Exhibit 21
Policy Change (Continued)
4
Other Changes
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.
(1) “Add or remove SBI”
(2) “Add/change/correct insured's authorized representative”
“Correct insured's
(3)
identification number”
Note: Provide instruction for the insured to
enter previous identification number if subitem (3) is checked.
(4) “Correct spelling of insured's name”
“Correct SBI’s identification
(5)
number”
Note: Provide instruction for the insured to
enter previous identification number if subitem (5) is checked.
(6) Correct the spelling of SBI’s name
“Add authority for designated person(s) to sign crop insurance documents on
behalf of the insured.”
A
“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
(7)
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.”
(8)
Substantive;
except for
sub-items 7
and 8 are
NonSubstantive
Remove authority for designated person(s) to sign crop insurance documents on
behalf of the insured.”
Note: For items 7 and 8, allow space for the insured to list all person(s) designated to
sign crop insurance documents on the applicant’s behalf. Indicate if person’s authority is
granted or removed.
5
A
6
A
B
C
7
Remarks
Create a space to enter explanations and/or remarks
Required Statements
Certification Statement
Privacy Act Statement
Nondiscrimination Policy Statement
Substantive
Exhibit 2
Exhibit 3
Exhibit 4
Substantive
Substantive
Substantive
Required Signatures
A "Applicant/Insured’s Printed Name, Signature and Date”
B “Agent’s Printed Name, Signature, Code Number and Date”
June 2015
FCIC 24040
Substantive
Substantive
63
Exhibit 22
Social Security Number and Employer Identification Number Reporting
1
Applicant/Insured’s Information
A
“Applicant/Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
2
“Applicant/Insured's Authorized Representative”
“Applicant/Insured's Street and/or Mailing Address”
“City and State”
“Zip code”
“[YEAR] and Succeeding Crop Years”
“Policy Number”
“Identification Number”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Identification Number Type”
“Person Type”
“Spouse’s Name”
Substantive
Substantive
Substantive
“Spouse’s Identification Number”
Substantive
Other Person(s) Information
“List all person(s) 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.”
A
Required Information: (Title and Items 1-6
are Substantive)
1.
2.
3.
4.
5.
6.
3
Name
Address
Telephone number
Identification Number
Identification Number Type
Person Type
Note: Include a note regarding
additional space if needed to complete
lists, e.g., (See reverse side for additional
space)
Substantive
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
C
“Agent’s Street and/or Mailing Address
Substantive
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
June 2015
FCIC 24040
64
Exhibit 23
Acreage Report
The Acreage Report is required annually and determines the number of reported acres, liability, or
amount of insurance provided, premium, and establishes the insurable share at the time insurance
attaches. The standards below represent all Acreage Report elements for standards identified in the
CIH and GSH. The AIP may use all terms for one Acreage Report type or only those standards that
are applicable for the applicable policy (e.g., multiple Acreage Report Types). See the GSH and CIH
for further completion and application instructions.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
M
N
2
A
B
C
E
D
E
F
“Insured’s Authorized Representative”
Substantive
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
Substantive
“Person Type”
Substantive
G
H
I
J
“Landlord/Tenant insuring other’s share”
See Para. 411
Substantive
“Spouse’s Name”
Substantive
“Spouse’s Identification Number”
Substantive
“Spouse’s Identification Number Type”
Substantive
Crop Information
“Crop Year”
“Crop”
“State and County”
“Plan of Insurance”
“Options, Elections, or Endorsements”
“Type”
“Practice”
“Unit Number”
“Unit Structure Code”
“Coverage Level”
“Acreage Type”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
K
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
June 2015
FCIC 24040
65
Exhibit 23
Acreage Report (Continued)
2
L
Crop Information (continued)
“FSA Farm/Tract/Field
Number”
Note: Non-Substantive for Apiculture Acreage
Reports.
Substantive/
NonSubstantive
Provide the following instruction:
“This item is optional except for the following situations:
Acreage insured under written agreement, if required by written agreement as
(1)
determined by the RMA Regional Office;
M
(2)
Acreage emerging from CRP the initial year of planting, and all subsequent
crop years thereafter;
(3)
Acreage being planted the initial year of new breaking and all subsequent crop
years thereafter; and
(4)
Units are based on FSA Farm Number (with tract/field number optional)”
Note: Substantive for those plans that use approved
APH yields.
Note: Or, “Number of Trees”, “Number of Pounds,”
or “Insured Acres by Grid”
NonSubstantive
N
“Approved APH Yield”
O
"Reported Acres”
P
Divide column and label “Whole” and “10ths or 100ths” underneath “Reported
Acres/Number of Trees or Pounds”
NonSubstantive
Q
“Acreage Determination
Source”
NonSubstantive
R
S
T
U
V
Note: To become Substantive requirement in next
issuance of DSSH
Substantive
Substantive
“Measurement Service”
“Insured's Share”
“Name of Other Person(s) Sharing in the Crop”
“Date Planting Completed”
“Area Classification”
“Percentage Price Election, Projected Price, or Amount of Insurance, or Protection
Factor”
Substantive
Substantive
Substantive
Substantive
Substantive
X
“Grid ID”
Y
“Intended Use”
Z
“Total Insurable Acres”
Note: Substantive for Pasture, Rangeland, Forage
Only: Total Insurable Acres of the crop in which the
insured has a share.
AA
“Total Number of Colonies in
the U.S.”
Note: Substantive for Apiculture Only. Total
number of colonies in which the insured has a share.
Substantive/
NonSubstantive
Substantive/
NonSubstantive
Substantive/
NonSubstantive
BB
“Total Number of Hives of
Insured Colonies”
Note: Substantive for Apiculture Only. Number of
Hives of insured colonies assigned to the Grid ID.
Substantive/
NonSubstantive
CC
“Remarks”
W
June 2015
Note: Substantive for RI/VI Acreage Reports only.
Substantive
Substantive
FCIC 24040
66
Exhibit 23
Acreage Report (Continued)
Required Statements
3
Provide the following question above the Certification Statement.
A
“I have verified my identification number affixed to this Acreage Report is true and
accurate. Yes No. If the affixed identification number is not correct or you have
not had an opportunity to verify your identification number please contact [INSERT
AIP CONTACT POINT] and submit a Policy Change.”
NonSubstantive
“I certify that I am responsible for
establishing the approved APH yields
that are used to calculate the production
guarantees contained in this acreage
report and that such approved APH
yields are correct to the best of my
knowledge.”
Note: Provide the following Certification
Statement above the Agent’s signature.
Substantive only for those policies that use
an approved APH yield to establish the
guarantee
Substantive/
NonSubstantive
C
“I HAVE or HAVE NOT broken
native sod after February 7, 2014”.
Note: Substantive only for states subject
to Native Sod provisions. Provide the
following Statement above the Insured’s
signature for States subject to the Native
Sod Provisions:
Substantive/
NonSubstantive
D
“The colonies noted above qualify as
apiculture and the selected index
intervals support the vegetation
production necessary for the colonies.”
Note: Substantive for Apiculture Only.
Provide the following Statement above the
Insured’s signature on Acreage Reports
subject to the Apiculture Provisions:
Substantive/
NonSubstantive
E
“To the best of my knowledge, the Grid
ID accurately identifies the location of
the insured acreage; and acreage
assigned to each Grid ID is accurate.”
Note: Substantive for Apiculture Only.
Provide the following Statement above the
Insured’s signature on Acreage Reports
subject to the Apiculture Provisions:
Substantive/
NonSubstantive
F
USDA Multiple Benefit Certification Statement
Exhibit 5
Substantive
G
Certification Statement
Exhibit 2
Substantive
H
Privacy Act Statement
Exhibit 3
Substantive
I
Nondiscrimination Policy Statement
Exhibit 4
Substantive
B
4
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Date and Code Number”
Substantive
June 2015
FCIC 24040
67
Exhibit 24
Summary of Coverage (Schedule of Insurance)
This form is issued to the insured after the crop(s) is planted, reports his/her acreage, and the AIP has
calculated the associated premium and liability. The AIP has the election of titling this form either the
Summary of Coverage or the Schedule of Insurance.
1
Insured Information
A
B
C
D
E
F
G
H
“Insured’s Name”
Substantive
“Street and/or Mailing Address”
“City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
I
“Person Type”
J
“SBI’s Name”
K
“SBI’s Identification Number”
L
“SBI’s Identification Number Type”
M
“SBI Person Type
N
2
A
B
“Policy Number”
Substantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
Substantive
Note: To become Substantive requirement
in next issuance of DSSH.
Note: To become Substantive requirement
in next issuance of DSSH
Crop Information
“Crop Insured”
“Crop/Practice/Type”
Substantive
Substantive
C
“Percentage Price Election, Projected
Price, Amount of Insurance, or Protection
Factor”
D
E
F
G
H
I
J
K
“Coverage Level”
“Options, Elections, or Endorsements”
“Effective Crop Year”
“Plan of Insurance”
“State and County”
“Guarantee or Amount of Coverage”
“Liability”
“Insured’s Premium”
June 2015
Note: Substitute “Productivity Factor” for
RI/VI applications. AIPs may include the
applicable term for the appropriate plan of
insurance.
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
FCIC 24040
68
Exhibit 24
Summary of Coverage (Schedule of Insurance) (Continued)
2
Crop Information (continued)
L
“Insurable Acres”
M
“Insured Acres”
N
“Insured’s Share”
O
“Grid ID”
P
“Index Interval”
Q
“Trigger Grid Index”
R
“FSA Farm Number, Tract, and Field”
S
“Policy Protection per Unit”
T
“Percent of Value”
U
3
A
B
C
D
E
F
4
Note: Substantive for RI/VI Only
“Intended Use”
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive/NonSubstantive
Substantive
Agent Information
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
“Agent’s Code Number”
“Agent’s Telephone Number”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Other Information
The AIP shall display the A&O subsidy amount based on the full 2.3 percent
reduction, but shall include a footnote stating the following:
A
“*Note: This amount may increase by 1.15 percent of net book premium (except
for area plans of insurance) if the loss ratio in the State exceeds 1.20 or may
otherwise change if required by the Standard Reinsurance Agreement. However,
the amount of premium you are required to pay will not change.”
Substantive
Alternatively, the actual dollar amount that is the difference between the 2.3
percent reduction and the 1.15 percent reduction may be substituted for the phrase
“...1.15 percent of net book premium...” in the above footnote.
B “Date Issued”
C “Amount of Administrative Fee Due the Approved Insurance Provider”
D “Amount of Subsidy Paid by RMA”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
69
Exhibit 25
Policy Confirmation (Policy Declaration)
This form is issued to the insured after the AIP accepts the completed application. The AIP has the
election of titling this form the Policy Confirmation or the Policy Declaration.
1
Insured Information
A
B
C
D
E
F
G
H
I
J
K
L
M
N
“Insured’s Name”
Substantive
“Street and/or Mailing Address”
“City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
“Person Type”
Substantive
Substantive
O
“SBI Person Type
2
A
B
Crop Information
C
D
E
F
G
H
I
J
K
3
A
B
C
D
E
F
“Spouse’s Name”
Note: To be removed in next issuance of
DSSH.
“Spouse’s Identification Number”
“SBI’s Name”
Substantive
Substantive
Non-Substantive
“SBI’s Identification Number”
Note: To become Substantive requirement
in next issuance of DSSH
“SBI’s Identification Number Type”
Non-Substantive
Non-Substantive
Non-Substantive
“Crop Insured”
“Crop/Practice/Type”
Substantive
Substantive
Note: Substitute “Productivity Factor” for
RI/VI applications. AIPs may include the
applicable term for the appropriate plan of
insurance.
“Percentage Price Election, Projected
Price, Amount of Insurance, or
Protection Factor”
“Coverage Level”
“Options, Elections, or Endorsements”
“Effective Crop Year”
“Plan of Insurance”
“State and County”
“Grid ID”
Note: Substantive for RI/VI Applications
“Index Interval”
only.
“Percent of Value
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/Non
-Substantive
Agent Information
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
“Agent’s Code Number”
“Agent’s Telephone Number”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
70
Exhibit 26
Power of Attorney
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 and also the
applicable state laws that govern power of attorney documents. Agent and loss adjuster use of a power
of attorney form may be limited by conflict of interest requirements contained in the SRA. Refer to
GSH.
1
Required Language
“The undersigned does hereby make, constitute and appoint [INSERT NAME OF
APPOINTEE] in the County of [INSERT COUNTY OF EXECUTION] and State of
[INSERT STATE OF EXECUTION], 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 [INSERT POLICY 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)
A
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.
Substantive
(7) Providing program required production reports.
(8)
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 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 [DAY] day of
[MONTH], [YEAR].”
2
A
B
C
D
Required Signatures
“Witness’s Printed Name, Signature, and Date”
“Insured’s Printed Name, Signature, and Date”
“I hereby accept the foregoing appointment”
“Appointee’s Printed Name, Signature, and Date”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
71
Exhibit 26
Power of Attorney (Continued)
3
Acknowledgement Block
Note: Use the acknowledgment
block if required by the State
where acknowledgment is taken.
Example:
ACKNOWLEDGMENT
[For use by Notary Public]
State of [INSERT STATE OF EXECUTION]
County of [INSERT COUNTY OF EXECUTION]
On this, the [DAY] day of [MONTH], [YEAR],
A before me a notary public, the undersigned officer,
personally appeared [INSERT NAME OF
INSURED], known to me (or satisfactorily proven)
to be the person whose name is subscribed to the
within instrument, and acknowledged that [HE OR
SHE] executed the same for the purposes therein
contained.
In witness hereof, I hereunto set my hand and
official seal.
B “Notary Seal and Signature of Notary”
This statement appears only as an
example acknowledgement
statement. The AIP may use any
similar statement it elects in
accordance with state law. Any
existing and/or executed Power of
Attorney documents do not need
to be revised.
Substantive
The acknowledgement may be
modified for various person types,
e.g., corporation, partnership,
LLC, to be contractually
consistent with state law.
Signatures of the insured and the
appointee must be notarized when
required by law. Witness
signatures are not required if
notarized
Note: Substantive, as required by
state law.
Required Statements
A Privacy Act Statement
B Nondiscrimination Policy Statement
Substantive
4
June 2015
FCIC 24040
Exhibit 3
Substantive
Exhibit 4
Substantive
72
Exhibit 27
Assignment of Indemnity
An insured may assign the right to an indemnity payment for a crop(s) under a policy to a creditor(s) or
other persons to whom the insured has a financial debt or other pecuniary obligation by using an
Assignment of Indemnity. The assignment(s) applies for all acreage of the crop covered by the policy.
Refer to the GSH.
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Insured's Authorized Representative”
Substantive
C
D
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
E
“Zip Code”
Substantive
“Policy Number”
F
“Effective Crop Year”
G
2 Terms and Conditions
The assignment must read as follows:
A
B
C
Substantive
Substantive
Note: The Name
“The Insured assigns to [NAME OF CREDITOR] of
and Address of
[MAILING ADDRESS] [CITY, STATE and ZIP] the right
Creditor must be
Substantive
and interest of any indemnity payment(s) which may be
contained in above
payable to the insured under the insurance policy for the
statement unless
county/commodity (ies) shown:” e.g., [1ST CROP NAME
listed on the form.
ND
AND COUNTY NAME] [2 CROP NAME AND COUNTY
NAME]”
“Conditions”
“This assignment will be binding upon the person(s) who succeed the insured’s
(1)
interest in the insurance policy.”
“Indemnity payments made under the insurance policy will be subject to a
(2) deduction for any indebtedness due this Approved Insurance Provider by the
insured.”
“This assignment will not grant the Creditor any greater rights than originally
(3)
held by the insured.”
“The Creditor’s interest will be recognized upon Approved Insurance Provider’s
(4) approval of this assignment and the Creditor will have the right to submit the
Substantive
loss notices and other forms as required by the insurance policy.”
“The Approved Insurance Provider will determine the person(s) entitled to any
(5)
indemnity payment(s) and the payment(s) will be by joint check.”
“Cancellation of this assignment prior to and during the crop
Note: Followed
year stated above will be accepted by the Approved
by signatures of
Insurance Provider only upon notification in writing by the
the Insured,
(6)
above identified Creditor(s). It is understood and agreed that
Creditor and
this assignment will be subject to the terms and conditions of
Witnesses)
the insurance policy.”
“If the assignment is not canceled according to item (6), the assignment will
(7)
cease at the end of the effective crop year.”
“This assignment was filed with the Approved Insurance Provider on [DAY], [YEAR]
at [INSERT HOUR] a.m. /p.m.”
June 2015
FCIC 24040
Substantive
73
Exhibit 27
Assignment of Indemnity (Continued)
3
Required Statements
A
Privacy Act Statement
Exhibit 3
Substantive
B
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
Required Signatures
A
B
C
“Insured’s Printed Name, Signature and Date”
“Creditor’s Authorized Representative Printed Name, Signature and Date”
“Creditor’s Authorized Representative’s Telephone Number”
Note: Both the Insured’s and
Creditor’s signature and date as
“Witness Printed Name, Signature and Date”
provided in item A & B must contain
a Witness signature and date.
Substantive
Substantive
Substantive
“AIP’s Authorized Representative Printed Name, Signature and Date”
Substantive
D
E
June 2015
FCIC 24040
Substantive
74
Exhibit 28
Continuous Hail and Fire Exclusion Option
1
Insured Information
A
“Insured’s Name”
B
“Street and/or Mailing Address”
2
Substantive
NonSubstantive
Crop Information
A
“The Hail and Fire Exclusion Option applies to the following crop(s):”
Substantive
B
“State and County Where Insurance Attaches”
Substantive
C
“Policy Number”
Substantive
D
“First Effective Crop Year”
Substantive
3
Terms and Conditions
“Hail and Fire will be excluded on a crop basis as insured causes of loss from your
[ENTER CROP INSURANCE POLICY] for a reduced premium for each crop year
the following terms and conditions are met.”
A
“The terms of this option apply to the first crop year it is requested and to each
succeeding crop year as provided below. Crops can be added to this option if a written
request is submitted on or before the date crop insurance coverage attaches for the
crop(s). To cancel this option or delete a crop(s), you must submit a request in writing
on or before the applicable cancellation date for the crop(s).”
Substantive
“To exclude hail and fire insurance, for the first crop year of this option:”
B
(1)
“The Hail and Fire Exclusion Option must be signed within 72 hours of the date
a private Hail and Fire policy is first in effect. If a multi-season hail and fire
policy is in effect, after the first crop year the multi-season hail and fire policy is
in effect, you may sign the Hail and Fire Exclusion Option on or before the date
coverage attaches for a crop year.”
(2)
“This option is effective only if the crop has not been damaged to the extent that
a crop insurance indemnity may be claimed on any unit of the insured crop.”
(3)
“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
crop insurance policy and the total dollar amount of hail and fire insurance
liability must equal or exceed the total crop insurance policy liability for that
crop acreage. To determine if sufficient hail and fire liability is in place for a
revenue protection plan of insurance policy or a revenue protection with the
harvest price exclusion plan of insurance policy, the amount of liability (for this
purpose only) will be computed based upon the projected price.”
(4)
“For each crop year, you must provide a copy of the annual hail and fire
declaration sheet showing you have purchased the minimum amount of hail and
fire coverage for the crop year to cover your liability or provide other acceptable
proof that the minimum amount of hail and fire coverage has attached for the
crop year.”
(5)
“An appraisal for uninsured causes will be made if the crop is damaged by hail
and/or fire, and the average percent of damage to the crop insurance unit
exceeds the deductible percentage for the crop insurance policy.”
June 2015
FCIC 24040
Substantive
75
Exhibit 28
Continuous Hail and Fire Exclusion Option (Continued)
3
Terms and Conditions (continued)
“The appraised amount of production is determined by:
(a) Subtracting the crop insurance policy coverage level from 1.00
B
(6)
(b) Subtracting the result of (a) from the percentage of hail and/or fire
damage;
Substantive
(c) Multiplying the result of (b) by the production guarantee per acre for the
applicable crop insurance policy; and
(d) Dividing the result of (c) by the crop insurance policy coverage level
percentage.”
“Example: The average percentage hail damage to the crop insurance unit = 45%.
The crop insurance policy coverage level = 65%. Per-acre guarantee = 100.0 bu.
C
STEP
1
1.00 - 0.65 (coverage level percentage) = 0.35 (deductible)
STEP
2
0.45 (average percentage hail damage) - 0.35 (deductible) = 0.10 (excess
percentage)
STEP
3
0.10 (excess percentage) x 100.0 bu. (per-acre guarantee) = 10.0 bushels
STEP
4
10.0 bu. ÷ 0.65 (crop insurance coverage level) = 15.4 bu. per-acre appraisal
for uninsured causes.”
NonSubstantive
“Except that:
D
4
A
B
C
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 crop insurance coverage, due to another cause
of loss insured under the crop 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 crop
insurance guarantee per acre and divided by your coverage level percentage. The
result will be the appraisal for uninsured causes.”
Substantive
Other Information
“Information for the first-year hail and/or fire exclusion request.”
(1) “Hail and Fire Coverage Effective Date"
(2) “Name of Hail and Fire Insurance Company (ies) and Policy Number(s)”
“Name and Address of Approved Insurance Provider”
“I, the insured, certify that the information reported above is
true and accurate. I will provide any information the
Approved Insurance Provider (or Authorized
Representative(s) of the Approved Insurance Provider) may
require. I will provide 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 force.”
June 2015
FCIC 24040
Note: This statement
is required above the
insured’s signature
line.
Substantive
Substantive
Substantive
76
Exhibit 28
Continuous Hail and Fire Exclusion Option (Continued)
5
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
6
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
77
Exhibit 29
Annual Request to Exclude Hail and Fire
1
Insured Information
A
“Insured’s Name”
B
“Street and/or Mailing Address”
2
Substantive
NonSubstantive
Crop Information
A
“The Annual Request to Exclude Hail and Fire applies to the following crop(s):”
Substantive
B
“State and County Where Insurance Attaches”
Substantive
C
“Policy Number”
Substantive
D
“Effective Crop Year”
Substantive
3
Terms and Conditions
A
“Hail and Fire will be excluded on a crop basis as insured causes of loss from your
[INSERT NAME OF CROP INSURANCE POLICY] for a reduced premium for the
effective crop year provided the following terms and conditions are met.”
Substantive
“For the effective crop year of this request:”
“The Request to Exclude Hail and Fire must be signed within 72 hours of the
date a private hail and fire policy is in effect. If a multi-season hail and fire
(1) policy is in effect, after the first crop year the multi-season hail and fire policy is
in effect, you may sign the Annual Request to Exclude Hail and Fire on or
before the date your crop insurance coverage attaches for a crop year.”
B
(2)
“Hail and Fire insurance coverage must be in effect (and premiums earned) on
all planted insurable acreage of the crop insured under the crop insurance policy
and the total dollar amount of hail and fire insurance liability must equal or
exceed the total crop insurance liability for that crop acreage.”
(3)
“To determine if the minimum required hail and fire liability is in place for a
revenue protection plan of insurance policy, or revenue protection with the
harvest price exclusion plan of insurance policy, the amount of liability (for this
purpose only) will computed based upon the projected price.”
(4)
“You must provide a copy of the private hail and fire declaration sheet showing
you have purchased at least the required minimum amount of hail and fire
coverage for the effective crop year to cover your liability or other acceptable
proof coverage has attached.”
(5)
Substantive
“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 deductible percentage for the crop insurance policy.”
“The appraised amount of production is determined by:
(a) Subtracting the crop insurance policy coverage level from 1.00
(b) Subtracting the result of (a) from the percentage of hail and/or fire damage;
(6)
(c) Multiplying the result of (b) by the production guarantee per acre for the
crop insurance policy; and
(a) Dividing the result of (c) by the crop insurance policy coverage level
percentage.
June 2015
FCIC 24040
78
Exhibit 29
Annual Request to Exclude Hail and Fire (Continued)
3
Terms and Conditions (continued)
“Example: The average percentage hail damage to the crop insurance unit = 45%.
The crop insurance policy coverage level = 65%. Per-acre guarantee = 100.0 bu.
C
STEP
1
1.00 - .65 (coverage level percentage) = 0.35 (deductible)
STEP
2
0.45 (average percentage hail damage) - 0.35 (deductible) = 0.10 (excess
percentage)
STEP
3
0.10 (excess percentage) x 100.0 bu. (per-acre guarantee) = 10.0 bushels
STEP
4
10.0 bu. ÷ 0.65 (crop insurance coverage level) = 15.4 bu. per-acre appraisal
for uninsured causes.”
NonSubstantive
“Except that:
D
4
A
B
C
5
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 crop insurance coverage, due to another cause
of loss insured under the crop 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 crop
insurance guarantee per acre and divided by your coverage level percentage. The
result will be the appraisal for uninsured causes.”
Substantive
Other Information
“Information for the first-year hail and/or fire exclusion request.”
(1) “Hail and Fire Coverage Effective Date"
(2) “Name of Hail and Fire Insurance Company (ies) and Policy Number(s)”
“Name and Address of Approved Insurance Provider”
“I, the insured, certify that the information reported above is
true and accurate. I will provide any information the
Approved Insurance Provider (or Authorized
Representative(s) of the Approved Insurance Provider) may
require. I will provide 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 force.”
Substantive
Substantive
Note: This statement
is required above the
insured’s signature
line.
Substantive
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
6
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
79
Exhibit 30
High-Risk Land Exclusion Option
The BP provides insurance coverage on all insurable acres planted to a crop in the county. When
coverage and rates are provided in the actuarial documents for high-risk land, insureds are required to
insure the high-risk land at an increased cost reflective of the increased risk. Insureds who do not wish
to insure high-risk land on an additional coverage policy may amend the BP by signing and submitting
the High-Risk Land Exclusion Option (by crop(s) and policy) to the AIP. See CIH for further
instruction regarding this option.
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Street and/or Mailing Address”
Substantive
C
D
E
F
G
H
I
“City and State”
“Zip Code”
“Insured’s Telephone Number”
Substantive
Substantive
Substantive
“Policy Number”
Substantive
“State and County”
Substantive
“Identification Number”
Substantive
“Identification Number Type”
Substantive
2
Crop Information
A
“Crop(s)”
Substantive
B
“Crop Year”
Substantive
3
Terms and Conditions
“Upon our approval of this option, we agree to amend your Common Crop Insurance
Policy Basic Provisions 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
(1)
“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.”
(2)
“By signing this option, you are declining crop insurance coverage under the
Common Crop Insurance Policy Basic Provisions and the applicable crop
provisions on your high-risk land.”
(3)
“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).”
(4)
“This option may be canceled by either you or us for any succeeding crop year by
giving written notice on or before the applicable cancellation date provided by the
policy, preceding such crop year.”
(5)
“You must report, on the acreage report for each crop year, the acreage of the crop
planted on high-risk land.”
(6)
“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.
(7)
“All other provisions of the policy not in conflict with this option are applicable.”
June 2015
FCIC 24040
Substantive
80
Exhibit 30
High-Risk Land Exclusion Option (Continued)
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
81
Exhibit 31
Transfer of Coverage and Right to an Indemnity
Use a Transfer of Coverage and Right to an Indemnity to transfer insurance coverage and the right to
any subsequent indemnity from one insured person to another person. The transfer is used when a
transfer of part or all of the ownership/share of the insured crop occurs during the insurance period.
See GSH for further instruction regarding this form.
1
Transferor Information
A
“Transferor’s Name”
Substantive
B
“Transferor’s Street and/or Mailing Address”
Substantive
C
D
E
“City and State”
“Zip Code”
“Policy Number”
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
F
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
2
Crop Information
A
“Crop(s)”
Substantive
B
“Crop Year”
Substantive
C
“Unit Number”
Substantive
D
“Is the entire insured acreage and the entire insured share on this unit being transferred?
Yes □ No □”
Note: Statement “(1)” below may be used alone. If both statements are used the form
should indicate “Check one of the boxes”.
“(1) □ Make check payable jointly to insured and transferee(s).
Substantive
Check will be mailed
to the insured’s address (unless an assignment of indemnity is on file); or
(2) □ Make checks payable to transferee(s) only. Check will be mailed to address
shown in 3B.”
“FSA Farm, Tract, Field Number”
“Grid ID”
Note: Substantive for RI/VI Only.
“Index Interval”
Substantive/
NonSubstantive
A
“Transferee’s Name”
Substantive
B
“Transferee’s Street and/or Mailing Address”
Substantive
C
D
E
“City and State”
“Zip Code”
“Policy Number”
Substantive
Substantive
Substantive
E
F
G
H
3 Transferee Information
June 2015
FCIC 24040
82
Exhibit 31
Transfer of Coverage and Right to an Indemnity (continued)
3 Transferee Information (continued)
“Transferee’s Identification Number”
F
G “Transferee’s Identification Number Type”
H “Person Type”
“Acreage Transferred”
I
“Share Transferred”
J
K “Effective Date of Transfer”
L
“Nature of Transfer”
4
Terms and Conditions
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“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:”
A
B
C
D
(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.”
“The Approved Insurance Provider shall not be liable for any more indemnity than
existed before the transfer occurred.”
“The insurance policy of the transferor covers the share hereby transferred only to the
end of the insurance period for the current crop year.”
“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 □”
Substantive
Substantive
Substantive
Substantive
E
$
“Total premium on this unit”
Substantive
F
$
“Premium on acreage transferred”
Substantive
G
$
“Premium on retained acreage”
Substantive
H
$
“Premium paid with transfer”
Substantive
June 2015
FCIC 24040
83
Exhibit 31
Transfer of Coverage and Right to an Indemnity (continued)
5
Required Statements
A
“I, [INSERT TRANSFEREE’S NAME], the Transferee,
understand that all billing statements and due process letters will
only be issued to [INSERT TRANSFEROR’S NAME], the
Transferor. Any unpaid premium and/or administrative fees on
the termination date of the policy will make both the transferee
and the transferor ineligible for the crop insurance program.”
Note: This
statement must
appear above the
signature line
Substantive
B
Certification Statement
Exhibit 2
Substantive
C
Privacy Act Statement
Exhibit 3
Substantive
D
Nondiscrimination Policy Statement
Exhibit 4
Substantive
6
Required Signatures
A
“Transferor’s Printed Name, Signature and Date”
Substantive
B
“Transferee’s Printed Name, Signature and Date”
Substantive
C
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
84
Exhibit 32
Production Report
The purpose of a production report is to collect the prior crop year(s)’ production from the insured and
the information contained within the production report is used to establish the approved APH yield for
the current year. An annual production report is required for all crops with a yield-based plan of
insurance that is required to establish the approved APH yield. For form completion instructions, see
also the CIH.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
“Crop Year”
“Identification Number”
“Identification Number Type”
Substantive
J
“Plan of Insurance”
2
Crop Information
A
“Crop”
“Practice/Type/T-yield Map Area/Other Characteristics”
“Unit Number”
B
C
Substantive
Substantive
Substantive
NonSubstantive
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
D
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
E
F
Substantive
Substantive
“Other Person(s)”
“Other”
June 2015
FCIC 24040
85
Exhibit 32
Production Report (Continued)
2 Crop Information (continued)
G “Record Type”
H “Processor Number/Name”
“Number Trees or Vines”
I
“Insurability”
J
Substantive
Substantive
Note: Items G-Q are required for the
Substantive
applicable crop year’s production report.
Substantive
These items are not required for all crop
Substantive
years within the base period unless the
Noninsured reports production for multiple
Substantive
crop years. The AIP developed form may
Substantive
have single crop year reporting or the
Substantive
AIP may adapt these standards to allow
Substantive
for multiple crop year reporting, when
Substantive
applicable.
NonSubstantive
Note: Provide instruction for the insured
to indication the applicable reason he/she
Substantive
is reporting a crop year other than the
most recent APH crop year.
K
“FSA Farm/Tract/Field Number”
L
“Cropland Acres”
M
N
O
P
“Crop Year of History”
“Total Production”
“Acres”
“Yields”
Q
“Insured Share”
R
“Multi Crop Year Reporting Reason
S
“New Producer □”
“I certify I have not produced the insured
crop in the county for more than two
years.”
Note: Non-Substantive, if the New
Producer Certification Form in Exhibit 63
is used, i.e., The Insured (including the
SBI) has produced the crop less than 3
years. Refer to CIH.
T
Added Land/New Crop/Practice/Type/TMA □ ”
U “State and County”
V “Area Classification”
3 Required Statements
Substantive
Substantive
Substantive
Substantive
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
B
“Comments”
June 2015
FCIC 24040
Substantive
NonSubstantive
86
Exhibit 33
Actual Production History Database
The production reports provided by the insured are used by the verifier to establish the APH database.
The APH database consists of all years of production (within the base period) reported by the insured
and is used to calculate the approved APH yield.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
2
A
B
C
D
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
“Crop Year”
“Identification Number”
Substantive
Substantive
Substantive
Crop Information
“Crop”
“Practice/Type/T-yield Map Area/Other Characteristics”
“Unit Number”
“State and County”
Substantive
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
E
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
F
G
H
I
J
K
L
M
N
O
P
Q
R
“Other Person(s) Sharing in the Crop”
“Other”
“T-Yield
“FSA Farm/Tract/Field Number”
“Crop Year of History”
“Total Production”
“Acres”
“Yields”
“Yield Descriptors”
“Total”
“Preliminary Yield”
“Prior Yield”
“Average Yield”
June 2015
Note: For items I-M, allow space to
provide the appropriate years of the
base period.
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
87
Exhibit 33
Actual Production History Database (Continued)
2 Crop Information (continued)
“Adjusted Yield”
S
“Rate Yield”
T
U “Approved Yield”
V “Required: □Field Review □Inspection”
3 Required Statements
A Privacy Act Statement
Nondiscrimination Policy Statement
B
4 Required Signatures
A
“Insured’s Printed Name, Signature and
Date”
B
“Comments”
June 2015
Substantive
Substantive
Substantive
Substantive
Exhibit 3
Substantive
Exhibit 4
Substantive
Note: Substantive if Insured elects YE
opt out. An insured is only required to
sign the APH database when YE is
elected and the insured has chosen to
opt-out of excluding an actual yield(s)
in eligible crop year(s).
Substantive
NonSubstantive
FCIC 24040
88
Exhibit 34
Withdrawal Claim for Indemnity
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Claim Number”
Substantive
F
“Policy Number”
Substantive
C
“Crop(s)”
Substantive
D
“Unit Number(s)”
Substantive
2
Terms and Conditions
“For the unit number(s) listed above, I withdraw this claim for indemnity
against the Approved Insurance Provider on this policy as of 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.”
A
Withdrawal
Statement
B
“□ I am electing benefits under another USDA program.”
Substantive
NonSubstantive
3
Required Statements
A
Privacy Act Statement
Exhibit 3
Substantive
B
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
A
Required Signatures
“Insured’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
89
Exhibit 35
Request for RMA Assigned Identification Number
Applicable to insured individuals or individuals 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 GSH procedures.
Such individuals may be assigned an identification number that can be used for insurance purposes.
Individuals 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 GSH
for documentation requirements for non-citizens and AIP instructions.
1 Applicant Information
A “[YEAR] and Succeeding Crop Years”
B “Applicant’s Name”
C “Applicant's Street and/or Mailing Address”
D “City and State”
E “Zip code”
F “State and County”
G “Policy Number (if applicable)”
H “Identification Number of Insured (if request is for SBI)”
I “Identification Number Type of Insured (if request is for SBI)”
J “Insured’s Person Type (if request is for SBI)”
Note: For example, Admitted for
Permanent Residence, Admitted as a
Refugee, Asylee, etc. Provide instruction
K “Documentation Type”
to “include a brief list of all attached
documentation, e.g., INS Form I-94”.
Refer to GSH.
“Is
this
request
to
renew
a
previously
issued
RMA
Assigned Number? Yes □ No □”
L
“If yes, list the previously issued RMA Assigned Number, the issue date, and the
M expiration date.”
2
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Required Signatures
A
“Applicant’s Printed Name, Signature and Date”
Substantive
B
“Insured’s Printed Name, Signature and Date”
Substantive
C
“AIP’s Authorized Representative’s Printed Name, Signature and Date”
D
“AIP’s Authorized Representative’s Street and/or Mailing Address
E
“AIP’s Authorized Representative’s Telephone Number”
Substantive
NonSubstantive
Substantive
June 2015
FCIC 24040
90
Exhibit 35
Request for RMA Assigned Identification Number
3
Required Statements
A
“I certify that [INSERT 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.”
Note: This
statement must
appear above the
AIP representative’s
signature line
Substantive
B
Certification Statement
Exhibit 2
Substantive
C
Privacy Act Statement
Exhibit 3
Substantive
D
Nondiscrimination Policy Statement
Exhibit 4
Substantive
June 2015
FCIC 24040
91
Exhibit 36
Request to Waive Administrative Fee for Limited Resource Farmer
The administrative fee for the Catastrophic Risk Protection Endorsement and additional coverage may
be waived for insureds who qualify as a limited resource farmer. See GSH for further information
regarding the waiver of administrative fees.
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Insured's Authorized Representative”
Substantive
C
D
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
E
“Zip Code”
Substantive
F
“County”
Substantive
G
“Identification Number”
Substantive
H
“Identification Number Type”
Substantive
I
“Policy Number”
Substantive
2
A
B
Terms and Conditions
“I, [INSURED’S NAME], request that the administrative fee
be waived for the [YEAR] crop year.”
“I certify that: ”
“I am a person with direct or indirect
gross farm sales not more than
[DOLLAR AMOUNT] in each of the
previous two years (to be increased
starting in fiscal year 2004 to adjust for
inflation using Prices Paid by Farmer
Index as compiled by the National
□ Agricultural Statistical Service (NASS);
and a total household income at or below
the national poverty level for a family of
four, or less than 50 percent of county
median household income in each of the
previous two years, to be determined
annually using Commerce Department
Data; or”
□
Note: The following
statements are
required.
Substantive
Note: Insert applicable dollar
amount as specified at
http://www.lrftool.sc.egov.usda.gov
Note: See
http://www.lrftool.sc.egov.usda.gov/
for the actual dollar amount adjusted
for inflation. The Limited Resource
Self Determination Tool may be
used to determine if an insured
qualifies as a limited resource
farmer.
Substantive
“I was insured prior to the 2005 crop year, or was insured for the 2005 crop year
for a crop with a contract change date prior to August 31, 2004, and
administrative fees were waived for one or more of those crop years because I
qualified as a limited resource farmer under the limited resource farmer
definition in effect at the time, and that I remain qualified as a limited resource
farmer under the definition that was in effect at the time the administrative fee
was waived.
If requested, I agree to provide records of income and acreage needed to
document my qualification as a limited resource farmer.”
June 2015
FCIC 24040
92
Exhibit 36
Request to Waive Administrative Fee for Limited Resource Farmer (Continued)
3
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“AIP Representative’s Printed Name, Signature, and Date”
Substantive
June 2015
FCIC 24040
93
Exhibit 37
Unit Division Option
Agents will prepare a Unit Division Option and transmit to the AIP for verification. See also, CIH for
form completion instructions.
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Street and/or Mailing Address”
Substantive
C
D
G
“City and State”
Substantive
“Zip Code”
Substantive
“State and County”
Substantive
E
“Plan of Insurance”
Substantive
F
“Policy Number”
Substantive
H
“Crop Year”
Substantive
2
Terms and Conditions
“Upon our verification of this option, we agree to amend the definition of optional units
when your Federal Crop Insurance Policy(ies) permit optional units by section subject to
the following terms and conditions:”
(1)
“You are allowed one Option per county that covers all applicable insured crops.
The Option must be submitted to us on or before the applicable acreage reporting
date for the crop before it is effective for that crop. If it is determined you have two
or more Options, the Option with the earliest date will be applicable to all crops and
the other Options(s) will be void.”
(2)
“You must aggregate legally identifiable parcels of land into parcels that contain a
minimum of 640 acres. The aggregation of parcels for optional units will be
established at the time you complete and sign this Option. Optional units are
established on the attached sketch map(s).”
(3)
“For each optional unit you must have available written verifiable records of
acreage and production for the previous crop year and maintain records for the
current crop year, and succeeding crop year’s in which this option remains in
effect.”
(4)
“Upon our request, if you fail to provide to us such records, optional units created
under this Option will revert to the basic unit(s).”
(5)
“Determination of your optional units will be made at the time you report your
acreage of the insured crop.”
A
(6)
“For crop(s) requiring production reports, to retain such optional units, acceptable
production reports must be filed by the Production Report Date, annually, for each
optional unit.
(7)
“This is a continuous option which may be canceled by either you or us for any
succeeding crop year by giving written notice on or before the cancellation date.
All other provisions of the policy not in conflict with this Option are applicable.”
June 2015
FCIC 24040
Substantive
94
Exhibit 37
Unit Division Option
3
A
B
C
D
4
Other Information
“Optional Units”
“Descriptions of Designated Parcels of
Land”
“Acres”
Note: Create a table with the following
columns for A-C.
Substantive
“Note: A map identifying the above must
be attached and numbered as ___ of ___.”
Note: Include this note below the table.
Substantive
Substantive
Substantive
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
C
D
Verified by □
“AIP Authorized Representative’s Printed
Name, Signature, and Date”
June 2015
Note: Affix item C above AIP Authorized
Substantive
Representative’s Signature:
FCIC 24040
95
Exhibit 38
RMA Regional Office Determined Yield Request
1
General Information
A
“Agent’s Name”
Substantive
B
C
D
“Agent’s Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
B
“Agent Code Number”
Substantive
E
“Telephone Number”
Substantive
F
“Email”
G
“Insured Name (as shown on the Application)”
NonSubstantive
Substantive
H
“Insured’s Street and/or Mailing Address
Substantive
I
"City and State”
Substantive
J
“Zip Code”
Substantive
K
“State and County”
Substantive
L
“State”
Substantive
M
N
O
“Policy Number”
“Crop Year”
“Identification Number”
Substantive
P
“Identification Number Type”
Q
Substantive
Substantive
Note: To become Substantive
requirement in next issuance of DSSH
“Insured is:
□ Landlord
□
□
NonSubstantive
Substantive
Operator
Owner/Operator”
2
Request Information
A
“Provide the following information for the
request:”
Note: Create a table with the following
column in B-N
Substantive
“Legal Description:”
___“Section:”
B
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
C
D
E
F
G
H
“Crop”
“Unit Number”
“Whole Acres”
“Plant Date”
“FSA Farm/Tract/Field Number”
“Practice”
June 2015
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
FCIC 24040
96
Exhibit 38
RMA Regional Office Determined Yield Request (Continued)
2 Request Information (continued)
“Type/Class/Variety
I
“Insured Share”
J
K “Name of Other Person(s) Sharing in the Crop”
L
“Request Type (check one):
□ Category B Crop(s)
□
Substantive
Category C Crop(s)
“Reason for this Request:”
Note: Create a checklist with the following
columns for items (1)-(12). Instruct the
requestor to select one of the reasons.
(1) □
“Master Yield (Category B Crop(s))”
(2) □
“Underage Crop (Category C Crop(s))”
(3) □
“Higher Yield Request (Category C Crop(s))”
(4) □
“Change in Practice or Production Methods (Category C Crop(s))”
(5) □
“High Variability Yield Adjustment (Category C Crop(s))”
Substantive
M
N
Substantive
Substantive
Substantive
(6) □
“Minimum Production Requirement (Category C Crop(s))”
(7) □
“New Producer and Variable T-Yield Exception (Category B Crop(s))”
(8) □
“Change in Person Type/Land Variable T-Yield Exception (Category B
Crop(s))”
(9) □
“Other Category B When Authorized by RMA in Writing and for Unusual
Cases or When Authorized in writing by RMA for Category C ”
(10) □
“Productivity is Reduced (Category C Crop(s))”
(11) □
“Irrigation Supply is Not Adequate (Category C Crop(s))”
“Explain Reason(s) for Regional Office Determined Yield Request”
June 2015
FCIC 24040
Substantive
97
Exhibit 38
RMA Regional Office Determined Yield Request (Continued)
3
A
B
4
Submission Documentation
Note: Create a checklist with the
following columns for items (1)-(9) for
supplemental documentation. All
necessary supplemental documentation is
contained in procedure. The instruction in
item A is non-substantive.
“Check all that apply”
(1) □
“Application/Policy Confirmation”
(2) □
“Current APH Database, including Production Reports for unit(s)”
(3) □
“Copy of Production Records substantiating any Crop Provisions minimums
that have been met – Category C Crops Only”
(4) □
“APH Block Production – Category C Crops Only”
(5) □
“Weighted Average Age/Density Worksheet(s) – Category C Crops Only”
(6) □
(7) □
“Producer’s Pre-Acceptance Worksheet(s) – Category C Crops Only”
“Perennial Crop Pre-Acceptance Inspection Report and Crop Addendum
Worksheets – Category C Crops Only”
(8) □
“Master Yield Summary APH Database
(9) □
“Other
NonSubstantive
Substantive
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“AIP Authorized Representative’s Printed Name, Signature, and Date”
Substantive
C
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
98
Exhibit 39
Summary of Revenue History Database
For Pecan Revenue only, the Summary of Revenue History Database consists of all years of
production, within the base period, reported by the insured and is used to calculate the approved SRH
yield.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
J
2
A
B
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
“Crop Year”
“Identification Number”
Substantive
Note: First Year Coverage Module
Substantive
Substantive
“Identification Number Type”
Substantive
“State and County”
Substantive
Crop Information
“Practice/Type/T-yield Map Area/Other Characteristics”
“Unit Number”
Substantive
Substantive
“Legal Description:”
___“Section:”
C
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
Substantive
Substantive
NonSubstantive
Substantive
D
E
“FSA Farm/Tract/Field Number”
“Other Person(s) Sharing in the Crop”
F
“T-Revenue”
G
H
“Crop Year of History”
“Gross Sales
I
“Total Pound Production”
J
K
L
M
N
O
P
Q
R
“Acres”
“Yield in Pounds”
“Average Gross Sales per Acre”
“Yield Descriptor”
“Total Number of Years”
“Total Gross Sales per Acre
“Approved Average Revenue per Acre”
“Yield Indicator”
“Required PAIR”
June 2015
Note: For items F-L, allow space to
provide the appropriate years of the
base period.
Note: For items N-R, ensure the rows
directly follow the columns in F-L
above.
FCIC 24040
Substantive
NonSubstantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
99
Exhibit 39
Summary of Revenue History Database (Continued)
3
A
4
Other Information
A
Privacy Act Statement
Exhibit 3
Substantive
B
Nondiscrimination Policy Statement
Exhibit 4
Substantive
Substantive
“Comments”
Required Statements
June 2015
FCIC 24040
100
Exhibit 40
Revenue Report
For Pecan Revenue, to collect the prior crop year(s)’ production and gross sales from the insured for
the prior two-year coverage module. The information contained in the revenue report is used to
establish the approved SRH yield for the current coverage module. A revenue report is required at the
beginning of a two-year coverage module.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
2
A
B
C
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
“Policy Number”
“Crop Year”
“Identification Number”
Substantive
“Identification Number Type”
Substantive
Crop Information
“Practice/Type”
Substantive
“State and County”
“Unit Number”
Substantive
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
D
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
E
F
G
H
I
J
K
“FSA Farm/Tract/Field Number”
“Other Person(s) Sharing in the Crop”
“Record Type”
“Contract Number”
“Number of Trees”
“Insurability”
“Gross Sales
L
“Total Pound Production”
M
N
O
P
“Acres”
“Yield Descriptor”
“Yield in Pounds”
“Average Gross Sales per Acre”
June 2015
Substantive
Substantive
Substantive
Substantive
Substantive
Note: Items G-P, are required for the
Substantive
most recent two crop year’s revenue
Substantive
report. These items are not required for
Nonall crop years within the base period
unless the insured reports production for Substantive
Substantive
multiple crop years.
Substantive
Substantive
Substantive
FCIC 24040
101
Exhibit 40
Revenue Report (Continued)
2
Crop Information (continued)
Q
“Multi Crop Year Reporting Reason”
R
“Added Acreage”
3
Other Information
A
4
Note: Provide instruction for the
insured to indication the applicable
reason he/she is reporting a crop years
other than the most recent two crop
years in the coverage module.
Substantive
Substantive
NonSubstantive
“Comments”
Required Statements
Certification Statement
A
Privacy Act Statement
B
Nondiscrimination Policy Statement
C
5 Required Signatures
A “Insured’s Printed Name, Signature, and Date”
June 2015
FCIC 24040
Exhibit 2
Exhibit 3
Exhibit 4
Substantive
Substantive
Substantive
Substantive
102
Exhibit 41
Agreement to Combine Optional Units
Use this form to allow a producer to combine multiple optional units into one optional unit. See also
the CIH.
1
Insured Information
A
“Insured’s Name”
Substantive
B
“Street and/or Mailing Address”
Substantive
C
D
E
F
G
“City and State”
“Zip Code”
“Agent’s Name”
Substantive
Substantive
Substantive
“Agent’s Street and/or Mailing Address”
Substantive
“State and County”
Substantive
H
“ Initial Crop Year”
Substantive
I
“Policy Number”
Substantive
2
Unit Information
A
“Applicable Crops”
Substantive
B
“Units Numbers Combined (Identify units by unit number)”
“Legal Description:”
Substantive
___“Section:”
C
___“Township:”
Substantive
___“Range:”
D
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
“FSA Farm/Tract/Field Number”
June 2015
FCIC 24040
Substantive
103
Exhibit 41
Agreement to Combine Optional Units (Continued)
3
Terms and Conditions
“This is a continuous agreement.”
(1)
“Upon our verification and approval of this Agreement, we agree to combine the
acreage and production history from separate APH databases for the combined
optional units for the insured crop(s) listed, into a single APH database by practice,
type or transitional yield map area, as applicable.”
(2)
“By signing this Agreement, you agree to farm two or more optional units as a
combined unit. Once approved, this option is continuous and remains in effect
unless the crop’s basic unit structure changes and those changes cause the combined
unit structure to be invalid or if the crop’s insurance policy is cancelled and
continuity of insurance coverage is broken.”
(3)
“The Agreement must be submitted to us on or before the production reporting date
for the applicable crop(s) and approved by us to be effective for the crop year. If not
submitted on or before the crop’s production reporting date, the option (if approved)
will be effective the succeeding crop year.”
(4)
“The optional units being combined must be located in the same county and in
separate sections, section equivalents or Farm Service Agency Farm Numbers (FSA
FNs), whichever is applicable.”
(5)
“The sections, section equivalents, or FSA FNs containing the optional units being
combined must adjoin (lie next to or be in contact with each other). A copy of an
aerial photograph or other map that clearly identifies the sections, section
equivalents or FSA FNs containing the optional units being combined that
demonstrates they adjoin must be attached.”
A
Substantive
If you transfer a crop’s policy on which the Agreement is in force to a different
insurance agency/AIP, the Agreement transfers with the crop’s policy and remains
in effect and you are not permitted to separate the combined units into additional
optional units. You must provide a copy of this Agreement to your new insurance
agency/AIP. If the Agreement is not transferred and you divide the combined unit
into optional units and the new insurance agency/AIP discovers that you have
divided a combined unit listed on this agreement into optional units:
(6)
The acreage and production history from the separate optional unit APH
databases will be combined according to this Agreement, beginning with the
crop year that the combined units were separated; and
If any indemnities were paid on the optional units, the approved APH yield
will be corrected for such crop years as indicated in a. above and the
(b)
indemnity will be recalculated. If the recalculated indemnity is less than the
indemnity that was paid when you violated the terms of this agreement, you
must pay the AIP the difference.”
“If the basic unit structure changes after this Agreement is approved, and the
combined unit must be divided into more than one basic unit, you must notify us
and recertify the acreage and production according to the land that is contained in
each basic unit no later than the crop’s production reporting date. If you fail to do
so, we will assign yields for such crop years that have planted acreage for the
applicable crops. The acreage and production and/or assigned yield applicable to
the land contained in each basic unit will be used to establish separate APH
databases for the new basic units.”
(a)
(7)
June 2015
FCIC 24040
104
Exhibit 41
Agreement to Combine Optional Units (Continued)
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“AIP Authorized Representative’s Printed Name, Signature, and Date”
Substantive
C
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
105
Exhibit 42
APH Block Production
Perennial Category C producers who report separate production and acreage by block use this
worksheet. The blocks on the production worksheet must correspond to the blocks on the Producer’s
Pre-Acceptance Worksheet. See the CIH and Exhibit 43.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Applicant’s/Insured’s Policy Number”
Substantive
C
D
E
“Unit Number”
“Crop”
“State and County”
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
F
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
G
“Crop Year”
Substantive
H
“FSA Farm/Tract/Field Number”
“Report all uninsurable block separately on this
form.”
“Include production that is less than minimums
and zero production.
Substantive
I
J
2
Substantive
Note: To be included after form title.
Substantive
Crop Information
Note: For each table created items A-F are to be created
A
“Crop Practice/Type”
Substantive
B
“Block Number”
C
“Month/Year”
D
“Set Out Year [YEAR]”
Substantive
E
“Density”
Substantive
Note: Coordinating block number from the Producer’s PreAcceptance Worksheet.
Note: Or, “Month and Year Planted”
Substantive
Substantive
Note: Allow space to provide the appropriate years of the base period for columns F-J.
F
“Crop Year of History”
G
“Production”
H
“Acres”
I
“Yield”
J
“T-Yield Adjustment”
June 2015
Note: Appropriate crop year(s) for the base period.
Note: Total production for the block as adjusted when
actual yields are reported.
Note: Planted acreage for the block in acres.
Note: Appropriate yield and yield descriptor for each crop
year.
Substantive
Substantive
Substantive
Substantive
Substantive
FCIC 24040
106
Exhibit 42
APH Block Production (Continued)
2 Crop Information (continued)
Note: Add below the table the following:
Substantive
K
“Average Yield”
Substantive
L
“Approved Yield”
Substantive
M
“Prior Yield”
Substantive
N
“Rate Yield”
Substantive
O
“Adjusted Yield”
Substantive
3
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
107
Exhibit 43
Producer’s Pre-Acceptance Worksheet
This worksheet applies to Category C Crops; refer to the CIH for form completion instructions. Some
standards below are crop specific modify this worksheet in crop information to the specific Category C
crop.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Applicant’s/Insured’s Policy Number”
Substantive
C
D
E
“Unit Number”
“Crop”
“State and County”
“Legal Description:”
Substantive
Substantive
Substantive
___“Section:”
F
___“Township:”
Substantive
___“Range:”
G
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
“Crop Year”
Substantive
H
“FSA Farm/Tract/Field Number”
Substantive
2
Crop Information
Note: Create a table for the following columns in A-P.
A
“Block Number”
Substantive
B
“Month/Year Planted”
Substantive
C
D
E
“Month/Year Grafted”
Substantive
“Variety”
Substantive
“Type”
Substantive
F
“Number of Plants”
G
“Plant Spacing”
Substantive
H
I
“Planting Pattern”
Substantive
“Acres”
Substantive
J
“Percent Stand”
Substantive
K
“Density”
L
“Insurable or Uninsurable”
M
“Spur or Nonspur”
Note: For Apples Only
Substantive
N
“Totals:”
Note: “For Acres and Number of Plants”
Substantive
June 2015
Note: Or, “Number of trees, vines, bushes”. N/A cranberries
or lowbush blueberries”
Note: N/A cranberries or lowbush blueberries
Substantive
Substantive
Substantive
FCIC 24040
108
Exhibit 43
Producer’s Pre-Acceptance Worksheet (Continued)
3
A
Required Questions
Yes
No
Create a block for the following questions, include a Yes � No � option at the
end of each question with instruction to check one.
□
□
(1) “Has damage (e.g., disease, hail, freeze) occurred to
Trees/Vines/Bushes/Bog that will reduce the insured crop’s production
from previous crop years?”
□
□
(2) “Have practices or production methods (e.g., removal, dehorning,
grafting, transitioning to organic) been performed that will reduce the
insured crop’s production from previous crop years?”
□
□
(3) “Is the current water supply (surface allotment/well) adequate to produce
a normal crop for the crop year being certified above?”
□
□
(4) Do the trees have sufficient vigor
to produce the average yield
computed for this unit?”
Note: For Florida Avocados Only
□
□
(5) Is the operator using organic or
other unconventional farming
practices? If yes, How long?”
Note: For Florida Avocados Only
Substantive
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
A
Required Signatures
“Insured’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
109
Exhibit 44
Perennial Crop Pre-Inspection Report
This report is to be completed by the AIP. See also, the CIH for form completion instructions.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Applicant’s/Insured’s Telephone Number
Substantive
C
“Applicant’s/Insured’s Policy Number”
Substantive
D
“Applicant’s/Insured’s Street and/or Mailing Address”
Substantive
E
“City and State”
Substantive
F
“Zip Code”
Substantive
G
H
I
J
K
“State and County”
“Name of Owner”
“Name of Operator”
“Crop”
“Crop Year”
Substantive
Substantive
Substantive
Substantive
Substantive
L
“Unit Number”
Substantive
“Legal Description:”
___“Section:”
M
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
N
“FSA Farm/Tract/Field Number”
Substantive
O
“Location Description”
Substantive
2
Required Questions for Inspector
Note: Create a question section, include items A-S to be completed by the Inspector.
A
“Number of Years Insured has operated this unit”
Substantive
B
“If less than 3 years, include previous owner’s name and address, if known”
Substantive
C
“Has this unit been insured in previous years?”
Substantive
D
“If yes, include the number of years insured and prior policy number(s)”
“Describe weed control measures used for the unit. Include a description of the
orchard/vineyard/plantation/bog floor management: (e.g., sterile/sod/cover crop)”
“Describe the fertilization program used for the unit. Include the insured’s method of
monitoring soil fertility (e.g., soil analysis, foliar analysis, or both)”
“Describe in detail insect control measures used (i.e., integrated pest
management/calendar spray program):
Substantive
E
F
G
Evidence of disease/insects (check one):
June 2015
□ Rare
FCIC 24040
□ Moderate
Substantive
Substantive
Substantive
□ Severe”
110
Exhibit 44
Perennial Crop Pre-Inspection Report (Continued)
2
H
Required Questions for Inspector (continued)
“Is a tree/vine/bush/bog replacement program being carried out?”
Substantive
“Crops Grown Primarily for: (Check one):
I
J
K
L
□ Fresh Market
□ Processor
□ Juice Market”
What date is/was harvest complete(d) for the unit under normal conditions?”
“Describe in detail the use and placement of bees for pollination. Include type, quality,
and location:”
• Surface: ____percentage of total supply
o Irrigation district name;
o Allocation last year: ___percentage of normal
o Expected allocation this year; ___percentage of
normal
“Describe in detail the
irrigation water source:”
• Irrigation Well(s): ___percentage of normal
o How many wells? ____
o Total gallons per minute? ___GPM
Substantive
Substantive
Substantive
Substantive
•
M
N
O
P
Water obtained through water transfer: ___acre feet per
acre”
“Is the unit subject to above normal flood hazards? If so, explain:”
“Are there soil limitations (i.e., slope, depth, drainage, ph, saline/alkali, toxicity)?” If so,
explain:”
“Describe in detail the pruning practices used; date normally completed, and indicate
whether pruning is annual or biennial:”
“Describe in detail the varieties being used as pollinator(s). Include variety/location,
quantity, density and configuration:”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
111
Exhibit 44
Perennial Crop Pre-Inspection Report (Continued)
3
Acreage/Inspection Information
B
“Measured or Determined Acres of Unit, Total Unit Acreage Insurable, and Uninsurable,
and Method of Measurement”
“Measured or Determined Acres of Unit, and Total Unit Acreage Insurable”
Substantive
C
“Determine whether current observed conditions reconcile to prior records”
Substantive
D
“Percent Stand”
• “Less than 50%
• 50-60%
• 61-70%
• 71-80%
• 81-90%
• 91-100%”
• “Based on original planting pattern
• Spaces occupied by live
trees/vines/bogs/bushes
• Bearing trees/vines/bogs/bushes
(percent stand)
• Insurable Stand”
Substantive
A
E
F
G
H
Substantive
Note: Create a table with the following
columns.
Substantive
Note: Add the following rows to the table
created in E above
Substantive
“Determine the current Unit potential: □Stable □ Declining □ Increasing (check one)”
“Do trees/vines/bushes/plant have sufficient vigor to produce the Preliminary APH yield
computed for this unit? □Yes □ No (check one)”
Substantive
Substantive
N
“Plant Vigor: □ Good □ Average □ Poor”
“If applicable, provide inside bin measurements:”
“Insurable acreage and tree/vine/bush/bog information: Complete and attach appropriate
crop addendum worksheet(s). Verify and/or correct Producer’s Pre-Acceptance
Worksheet(s)”
“Uninsurable acreage and tree/vine/bush/bog information:”
“Complete and attach appropriate crop addendum worksheet(s); Verify and/or correct
Producer’s Pre-Acceptance Worksheet(s).”
“Obtain and attach aerial photo(s)/map(s)”
Substantive
O
“Additional information and comments (attach additional sheets if necessary):”
Substantive
P
“Your evaluation of the management of the operation:”
Substantive
I
J
K
L
M
Q
R
“□ Above Average
□ Average
□ Below Average (check one)”
“Your evaluation of the orchard/vineyard/bog/grove conditions:”
T
“□ Above Average
□ Average
“Action Recommended:”
U
“□ Acceptance
S
4
□ Below Average (check one)”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
□ RMA RO Determined Yield Request
□ Rejection”
Substantive
Required Signatures
A
Adjuster Printed Named, Signature and Date
Substantive
B
Adjuster Telephone Number and Contact Point
Substantive
C
Supervisor Printed Name, Signature and Date
Substantive
D
Supervisor Telephone Number
Substantive
June 2015
FCIC 24040
112
Exhibit 45
Perennial Crop Addendum Worksheet(s)
This worksheet is to accompany the Pre-Acceptance Category C Crop Inspection Report when
necessary. Crop addendum worksheets are used to collect field inspection data specific to the crop
being inspected. The general information provided in Para. 1 applies to all individual crops identified
in Para. 2-10 below. Each separate Crop Information requirement constitutes a separate addendum by
crop in Para. 2-10. No signatures are required, for this worksheet is an addendum and should
accompany the applicable Inspection Report. For form completion instructions see also the CIH.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Crop Year”
Substantive
C
“Unit Number”
Substantive
D
“Insurable Acres”
Substantive
“Uninsurable Acres”
E
2 Apple – Crop Information
Substantive
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Planted or Grafted”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Number of Trees”
Substantive
F
“Plant Spacing”
Substantive
G
“Plant Pattern”
Substantive
H
“Rootstock”
Substantive
I
“Spur/Non-Spur”
Substantive
J
“Trellis Type, specify”
Substantive
K
“Frost Protection/System/Type/Number of Times”
Substantive
Substantive
M
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
N
“Irrigated/Non-Irrigated Type”
Substantive
L
O
P
Q
Note: Create a section for the following questions
“Describe current budwood/bough vitality and condition. Note the differences in
individual blocks, if applicable.”
“Has winter damage, or previous year damage occurred which may affect this year’s
potential production on any block? If yes, list block(s) and explain:”
“Remarks:”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
113
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
3
Peach – Crop Information
A
Note: Create a table with the following columns.
“Block Number”
Substantive
B
“Variety
Substantive
C
“Type”
Substantive
D
“Acres”
Substantive
E
“Month/Year Planted or Grafted”
Substantive
F
“Number of Trees”
Substantive
G
“Plant Spacing”
Substantive
H
“Plant Pattern”
Substantive
I
“Irrigated/Non-irrigated Type”
Substantive
J
“Percent Stand/ Number of Skips”
Substantive
K
“Fruiting Wood: <6”, 6-12”, >12” ”
Substantive
L
“Percent of Damage Limbs: <16%, 16-50%, >50%”
Substantive
M
“Disease: □ Rare □ Moderate □ Severe”
Substantive
N
“Average Trunk Diameter”
Substantive
“Pruning: □ Annual □ Biennial □ Other”
“Pruning by Block: Hand/Mechanical”
Substantive
O
P
Substantive
R
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
S
“Insect, Wildlife, Pests:
Substantive
T
Substantive
U
“Weed Control:
“Interplanted with another crop (specify crop)”
V
“Nematode Prevalence:
Q
Substantive
Substantive
□ Light □ Moderate □ Severe”
□ Good □ Fair □ Poor”
Substantive
□ Light □ Moderate □ Severe”
Substantive
Note: Create a section for the following questions
W
“List blocks interplanted for renovation purposes:”
Substantive
X
“Frost Protection: System/Type/Number of Times”
Substantive
Y
“Explain any tree damage which has occurred in the past five years:”
Substantive
“Was the soil pH above 6.0 on ALL blocks? □Yes
AA “List blocks which are terraced:”
Z
BB
□ No (check one)”
Substantive
Substantive
“Remarks:”
June 2015
Substantive
FCIC 24040
114
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
4
Pear– Crop Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Planted or Grafted”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Number of Trees”
Substantive
F
“Plant Spacing”
Substantive
G
“Plant Pattern”
Substantive
H
“Rootstock”
Substantive
I
“Spur/Non-Spur”
Substantive
J
“Trellis Type, specify”
Substantive
K
“Frost Protection/System/Type/Number of Times”
Substantive
Substantive
M
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
N
“Irrigated/Non-Irrigated Type”
Substantive
L
Q
Note: Develop a row for Acres and
Number of Trees
Note: Create a section for the following questions
“Has winter damage, or previous year damage occurred which may affect this year’s
potential production on any block? If yes, list block(s) and explain:”
“Describe fireblight protection methods used for the unit:”
R
“Remarks:”
O
P
5
“Totals:”
Substantive
Substantive
Substantive
Substantive
Substantive
Grape/Table Grape– Crop Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Planted or Grafted”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Number of Vines/Plant Bearing”
Substantive
F
“Plant Spacing”
Substantive
G
“Plant Pattern”
Substantive
H
“Rootstock”
Substantive
I
“Trellis Type/Condition”
Substantive
J
“Frost Protection/System/Type/Number of Times”
Substantive
Substantive
L
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
Substantive
M
“Irrigated/Non-Irrigated Type”
Substantive
K
June 2015
FCIC 24040
115
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
5
Grape/Table Grape– Crop Information (continued)
N
“Winter Damage”
O
“Totals:”
P
Note: Create a section for the following questions
“Describe the method of pruning (i.e., mechanical, mechanical + hand, mechanical +
combing + hand, hand)”
“If grafted, on double line entries:
Q
R
S
T
6
•
•
Note: Develop a row for Acres and Number of Vines
Substantive
Substantive
Month/year originally planted
Month/year grafted”
“Indicate type of phylloxera resistant rootstock (i.e., susceptible, AxR-1, etc):”
“If damaged by winter freeze, indicated month and year of freeze damage and crop year
when production resumed:”
“Remarks:”
Substantive
Cranberry– Crop Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Established”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Percent Stand”
Substantive
F
“Plant Pattern”
Substantive
G
“Totals:”
Note: Develop a row for Number of Acres
Substantive
Note: Create a section with columns for items I-K to answer item H.
H
“Previous loss history for the last four years”
Substantive
I
“Year”
Substantive
J
“Cause”
Substantive
K
“Extent of Damage”
Substantive
L
Note: Create a section with columns for items M-N to answer item L.
“Complete the following information for Cranberry bogs with less than 4 years of
production records”
“Improvements implemented since purchasing the bog:”
Substantive
M
June 2015
FCIC 24040
Substantive
116
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
6
Cranberry– Crop Information (continued)
“Specific Management practices utilized each year of operation on this bog:”
N
• “Management Practice”
• “Year”
Note: Create a table with the following
Column • “Year”
columns
• “Year”
• “Year”
• Fertilization Program”
• “Pruning Program”
• “Sanding Program”
• “Insect Program”
Row
Note: Add the following rows
• “Weed Program”
• “Bog Oxygen Program”
• “Water Supply”
• “Method of Harvest”
Note: Create a section for the following questions
Substantive
O
“Bog manager’s prediction of expected yield of this bog for the next 4 years:”
Substantive
P
“Explain previous bog manager’s experience:”
Substantive
Q
“Describe the use of frost warning system for the bog:”
“Describe the presence or absence of a backup power source for irrigation system and
type of system”
“Describe the backup security systems utilized for irrigation equipment:”
“Average number of times the frost protection system is used each year, If no frost
protection system is in place, enter none:”
“List by Block: Time needed to flood bog, and time needed to remove the water from
the bog.”
“Describe the insect detection methods used for the bog:”
Substantive
R
S
T
U
V
“Describe the general condition of bog dikes and banks:”
“Describe the pruning/sanding practices used, include the percentage of the bog pruned
and sanded last year, and the percentage of the bog pruned and sanded in the last five
X
years.”
“Harvesting Method: Include the method of harvest percentage of wet and dry last year
Y
and the percentage of wet and dry for the next year.”
“Attach a bog map showing each bog as a separate block. If a bog contains uninsurable
acreage or acreage undergoing a partial renovation, list such acreage as a separate
Z
block:”
AA “Remarks:”
W
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
117
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
7
Almond/Citrus/Fig/Fresh Plum/Macadamia Nut/Pecan/Prune/Stonefruit/Walnut– Crop
Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Planted or Grafted”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Number of Vines/Plant Bearing”
Substantive
F
“Plant Spacing”
Substantive
G
“Plant Pattern”
Substantive
H
“Rootstock”
Substantive
I
“Trellis Type/Condition”
Substantive
J
“Frost Protection/System/Type/Number of Times”
Substantive
Substantive
L
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
Substantive
M
“Irrigated/Non-Irrigated Type”
Substantive
N
“Totals:”
K
Note: Develop a row for Acres and Number of Trees
Substantive
Note: Create a section for the following questions
Substantive
Q
“Describe the varietal planting pattern (Almonds Only)”
“Has winter damage or previous year damage occurred which may affect this year’s
potential production on any block? If yes, list block(s) and explain:”
“Is frost protection adequate for citrus (WPF) with frost protection rate?”
R
“Remarks:”
Substantive
O
P
8
Substantive
Substantive
Low Bush Blueberry – Crop Information
Note: Create a table with the following columns.
A
“Field Identification”
Substantive
B
“First Year Insured ‘Fruit Bearing’”
Substantive
C
“Acres”
Substantive
D
“First Year Uninsured ‘Vegetative’”
E
“Acres”
Substantive
Substantive
F
“pH Value”
Substantive
G
“Irrigated/Non-Irrigated Type”
Substantive
H
“Type of Irrigation System and Average Times Used”
Substantive
I
“Type of Mulch Used and Percent of Bare Surface Covered”
Substantive
J
“Totals:”
Substantive
June 2015
Note: Develop a row for both columns.
FCIC 24040
118
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
8
Low Bush Blueberry – Crop Information (continued)
Note: Create a section for the following questions
K
L
M
N
O
P
Q
9
“Describe wildlife control measures:”
“Has winter damage or damage from the previous three years occurred which may affect
potential production on any fields?”
“Percent Harvested by method: ___Percent Hand Harvested ___Percent Mechanical
Harvested
“Does the applicant own a blueberry harvester? □Yes □ No (check one)”
“Describe record keeping system (i.e., processing, fresh market, roadside, u-pick):”
“Describe how the blueberries are marketed (i.e., cooperatives, associations, processors,
fresh market, wholesale, roadside, u-pick):”
“Remarks”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
High Bush/Rabbit Eye Blueberry – Crop Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Planted”
Substantive
C
“Variety”
Substantive
D
“Acres”
E
“Plant Spacing”
Substantive
Substantive
F
“Number of Bushes”
Substantive
G
“Acres”
Substantive
H
“Percent Stand”
Substantive
I
“Frost Protection System Type/Average Time Used”
Substantive
J
“Irrigated/Non-Irrigated Type”
Substantive
K
“pH Value”
Substantive
L
“Totals:”
Substantive
M
“Complete the following information for blueberry plantation.”
“Frost protection backup system: Describe the type of backup system, if no backup
system is in place, enter ‘none’:”
“Describe wildlife control measures:”
“Has winter damage or damage from the previous three years occurred which may affect
potential production on any block?”
“Percent Harvested by method: ___Percent Hand Harvested ___Percent Mechanical
Harvested
“Describe record keeping system (i.e., processing, fresh market, roadside, u-pick):”
Substantive
“Does the applicant own a blueberry harvester? □Yes □ No (check one)”
“Describe how the blueberries are marketed (i.e., cooperatives, associations, processors,
fresh market, wholesale, roadside, u-pick):”
“Remarks:”
Substantive
N
O
P
Q
R
S
T
U
Note: Develop a row for number of acres and number of
bushes.
Note: Create a section for the following questions
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
119
Exhibit 45
Perennial Crop Addendum Worksheet(s) (Continued)
10 Florida Avocado– Crop Information
Note: Create a table with the following columns.
A
“Block Number”
Substantive
B
“Month/Year Set Out, Grafted, or Stumped”
Substantive
C
“Acres”
Substantive
D
“Variety/Type”
Substantive
E
“Number of Trees”
Substantive
Substantive
G
“Air Drainage: □ Good □ Fair □ Poor”
“Percent Slope”
H
“Type of Irrigation”
Substantive
F
I
J
K
Note: Create a section for the following questions
“Has winter damage or previous year damage occurred which may affect this year’s
potential production on any block? If yes, list block(s) and explain:”
“Have Practices or Production Methods (e.g., removal, dehorning, grafting, transitioning
to organic) been performed that will reduce the insured crop’s production from previous
crop years?”
“Remarks:”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
120
Exhibit 46
Weighted Average Age/Density Worksheet
See the CIH for form completion instructions.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
C
D
E
F
G
“State”
Substantive
“County”
“Crop”
“Practice”
“Type”
Substantive
Substantive
Substantive
Substantive
“Variety/Other”
Substantive
H
“Crop Year”
Substantive
I
“Unit Number”
Substantive
J
“Policy Number”
Substantive
“Legal Description:”
___“Section:”
K
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
“FSA Farm/Tract/Field Number”
L
2 Crop Information
Substantive
Note: Create a table for the following columns in A-P.
A
“Block”
Substantive
B
C
D
E
F
G
“Month/Year”
Substantive
“Set Out Year”
Substantive
“Acres”
Substantive
“Set Out Year Extensions”
Substantive
“Density”
Substantive
“Acres”
Substantive
H
“Density Extensions”
Substantive
I
J
K
L
Note: Develop a Row for the Totals for Density x Acres and
Set Out Year x Acres
“Weighted Average Set Out Year
“Totals:”
Substantive
Substantive
“Weighted Average Density”
Substantive
“Transitional Yield”
Substantive
June 2015
FCIC 24040
121
Exhibit 47
Macadamia Orchard Inspection Report
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Applicant’s/Insured’s Street and/or Mailing Address”
Substantive
C
“Applicant’s/Insured’s Telephone Number”
Substantive
D
“County or Island”
Substantive
E
“Policy Number”
Substantive
F
G
H
I
“Agent Name”
“Street and/or Mailing Address”
“City and State”
Substantive
Substantive
Substantive
“Zip code”
“Check and verify all entries on the acreage
report. If any entries are questionable,
determine accuracy and correct, if necessary”
Substantive
J
2
A
B
C
Note: Include the following
instruction.
Substantive
Orchard Information
Note: Create a section for the following questions
“Describe the condition of other macadamia orchards owned or managed by
Applicant/Insured, if none, state none, if additional space is needed, enter additional
information in the Remarks section”
“Is the orchard managed by owner, yes or no, if no, specify who manages the orchard,
include manager’s name, address, and telephone number?”
“Is the orchard located in an established macadamia area, yes or no, if no explain the
general growing conditions and where the orchard is physically located. If additional
space is needed, enter additional information in the Remarks section”
Note: Create a table with the following columns.
Substantive
Substantive
Substantive
D
“Unit Number”
Substantive
E
“Variety”
Substantive
F
“Acres in Plot”
Substantive
G
“Tree Spacing”
Substantive
H
“Tree Count”
Substantive
I
“Month and Year Set”
“Tree Condition, Enter ‘Acceptable’ or ‘Unacceptable’, as applicable, explain any
unacceptable tree condition in the Remarks section.”
“Rate Area”
“Weed Control Measures: Enter one of the following, Chemical Weed Control (CWC),
Weed Control Without Chemicals (W/O CWC), or No Weed Control (NONE)”
“Excluded Acreage, explain why acreage is excluded in the Remarks section”
Substantive
J
K
L
M
June 2015
FCIC 24040
Substantive
Substantive
Substantive
Substantive
122
Exhibit 47
Macadamia Orchard Inspection Report (Continued)
3
A
Other Information
“The acreage covered by the above contract was inspected on the date shown below with
the following results:
(1) □ Nothing found to require a change in data reported.
(2)
Substantive
□ Data reported was found to be such that __________was prepared.
“Is the application/acreage report recommended for acceptance, check Yes, or NO”
B
C “Remarks:”
4 Required Signature
Substantive
Substantive
A
“Inspector’s Printed Name, Signature and Date”
Substantive
B
“Inspector’s Code Number”
Substantive
C
“Date of Inspection”
Substantive
June 2015
FCIC 24040
123
Exhibit 48
Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet
This worksheet applies to the Dollar Plan, Category D Crop, and Florida Citrus Fruit; refer to the CIH.
General Information
1
A
“Applicant’s/Insured’s Name”
B
“Applicant’s/Insured’s Street and/or Mailing Address”
Substantive
Substantive
C
“City and State”
Substantive
D
“Zip Code”
Substantive
E
“Applicant’s/Insured’s Telephone Number”
Substantive
F
“Applicant’s/Insured’s Policy Number”
Substantive
“Legal Description:”
___“Section:”
G
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
H
I
2
“Crop Year”
“State and County”
Substantive
Substantive
Crop Information
Note: Create a table for the following columns in A-Q.
A
“Block Number”
Substantive
B
C
D
“Unit Number”
“Crop”
“Date Set Out/Grafted”
Substantive
Substantive
Substantive
E
“Month/Year Topworked/Buckhorned”
Substantive
F
G
H
I
“Citrus Fruit Group”
Substantive
“Number of Trees”
Substantive
“Number of Trees Topworked/Buckhorned”
Substantive
“Planting Pattern”
Substantive
J
“Acres in Block”
Substantive
K
“Tree Spacing”
Substantive
L
“Percent Stand”
Substantive
M
N
O
“Number of Trees per Acre
Substantive
“Organic Practice”
Substantive
“Insurable or Uninsurable”
Substantive
P
“Totals:”
Q
Note: “Acres in Block, Number of Trees per Acre and
Number of Plants”
“Estimated Production Boxes”
June 2015
FCIC 24040
Substantive
Substantive
124
Exhibit 48
Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet
3
Orchard Information
Note: The following questions are to be completed by the insured with the assistance of
the AIP representative. Create a list of the following questions, and instruct the insured
to check/circle either “Yes” or “No” and fill in the blank, where applicable.
A
“Date of Last Inspection”
Substantive
B
“Has the dollar amount of insurance for the insured crop been previously adjusted due to
a reduction of the crop’s production potential?”
Substantive
C
“Has an adjustment been applied to the crop’s insurable acres resulting in a comparable
reduction in yield?”
Substantive
D
“Has damage (e.g., disease, hail, freeze) occurred to the trees that will reduce the insured
crop’s production?”
Substantive
E
“Have cultural practices or production methods (e.g., heavy pruning, transitioning to
organic) been performed that will reduce the insured crop’s production?”
Substantive
F
“Have trees been removed, buckhorned, topworked or replaced with uninsurable trees
resulting in a change of the original plant stand for any reported insurable acreage?”
Substantive
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
A
Required Signatures
“Insured’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
125
Exhibit 49
Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report
This report is to be completed by the AIP. Refer to CIH for form completion instructions.
1
General Information
A
“Applicant’s/Insured’s Name”
Substantive
B
“Applicant’s/Insured’s Telephone Number
Substantive
C
“Applicant’s/Insured’s Street and/or Mailing Address”
Substantive
D
“City and State”
Substantive
E
“Zip Code”
Substantive
F
“State and County”
Substantive
G
“Policy Number”
Substantive
H
“Name of Owner”
Substantive
I
“Name of Operator”
Substantive
J
“Crop Year”
Substantive
K
L
M
“Date Set Out/Grafted”
Substantive
“Month/Year Topworked/Buckhorned”
Substantive
“Planting Pattern”
Substantive
“Legal Description:”
___“Section:”
N
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
2 Individual Citrus Grove Data
A “Citrus Fruit Group”
“Unit Number”
B
Substantive
Substantive
C
“Block Number”
Substantive
D
“Acres in Block”
Substantive
E
“Tree Spacing”
Substantive
F
“Number of Trees”
Substantive
G
“Number of Trees per Acre
Substantive
H
I
“Tree Age in Years”
Substantive
“Insurable Condition”
Substantive
J
“Estimated Production Boxes”
Substantive
K
“Tree Condition”
Substantive
June 2015
FCIC 24040
126
Exhibit 49
Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)
2 Individual Citrus Grove Data (continued)
L
“Totals:”
M
“Excluded Acreage”
Substantive
Note: Include the following instruction: “Enter an (1) for
Production less than 100 boxes per acre; enter (2) if trees are
not of insurable age.”
“Fresh Fruit Records Verification”
N
3 Other Information
A
Create a Block Map. For example:
June 2015
Note: At minimum, map should be 8 rows
by 8 columns. The AIP can choose to
develop the block map on a form separate
from the report or use GPS in conjunction
with aerial photos or satellite imagery and
overlay with the information contained on
the plat map.
FCIC 24040
Substantive
Substantive
Substantive
127
Exhibit 49
Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)
4
Required Questions
Note: The following questions are to be completed by the insured with the assistance of
the AIP representative. Create a list of the following questions, and instruct the insured
to check/circle either “Yes” or “No” and fill in the blank, where applicable.
A
“Has the dollar amount of insurance for the insured crop been previously adjusted due to
a reduction of the crop’s production potential?” If yes, list block(s) and explain:”
Substantive
B
“Has an adjustment been applied to the crop’s insurable acres resulting in a comparable
reduction in yield?” If yes, list block(s) and explain:”
Substantive
C
“Has damage (e.g., disease, hail, freeze) occurred to the trees that will reduce the insured
crop’s production? If yes, list block(s) and explain:”
Substantive
D
“Have cultural practices or production methods (e.g. buckhorning, transitioning to
organic) been performed that will reduce the insured crop’s production? If yes, list
block(s) and explain:”
Substantive
E
“Have trees been removed, buckhorned, topworked or replaced with uninsurable trees
resulting in a change of the original plant stand for any reported insurable acreage? If
yes, list block(s) and explain:”
Substantive
F
“Describe weed control measures used for the unit. Include a description of the orchard
floor management: (e.g., sterile/sod/cover crop)”
Substantive
G
“Describe the fertilization program used for the unit. Include the insured’s method of
monitoring soil fertility (e.g., soil analysis, foliar analysis, or both)”
Substantive
H
“Describe in detail insect control measures used (i.e., integrated pest
management/calendar spray program):
Evidence of disease/insects (check one):
Substantive
□ Rare □ Moderate □ Severe”
I
“Is a tree replacement program being carried out?”
Substantive
J
“If applicable, is fumigation used in the replacement program?”
“Crops Grown Primarily for: (Check one):
Substantive
K
□ Fresh Market
June 2015
□ Processor
□ Juice Market”
FCIC 24040
Substantive
128
Exhibit 49
Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)
4 Required Questions (continued)
L
M
N
5
“Describe in detail the irrigation water
source:”
•
Surface: ____percentage of total
supply
o Irrigation district name;
o Allocation last year:
___percentage of normal
o Expected allocation this year;
___percentage of normal
•
Irrigation Well(s): ___percentage of
normal
o How many wells? ____
o Total gallons per minute? ___GPM
•
Water obtained through water transfer:
___acre feet per acre”
Substantive
“Is the unit subject to above normal flood hazards? If so, explain:”
“Are there soil limitations (i.e., slope, depth, drainage, Ph, saline/alkali, toxicity)?” If so,
explain:”
Substantive
Substantive
Acreage/Inspection Information
A
“Determine whether current observed conditions reconcile to prior records”
Substantive
B
“Percent Stand by Block”
• “Less than 50%
• 50-60%
• 61-70%
• 71-80%
• 81-90%
• 91-100%”
Substantive
C
D
E
F
G
•
•
•
•
“Based on original planting pattern
Spaces occupied by live trees
Bearing trees (percent stand)
Insurable Stand”
Note: Create a table with the following
columns.
Substantive
Note: Add the following rows to the table
created in item C above
Substantive
“Determine the current Unit potential: □Stable □ Declining □ Increasing (check one)”
“Measured or Determined Acres of Unit, and Total Unit Acreage Insurable”
“Do trees have sufficient vigor to produce the amount of insurance computed for this
unit? □Yes □ No (check one)”
Substantive
Substantive
Substantive
I
“Plant Vigor: □ Good □ Average □ Poor”
“Verify and/or correct Producer’s Pre-Acceptance Worksheet(s)”.”
Substantive
J
“Attach aerial photo(s)/map(s)”
Substantive
K
“Additional information and comments (attach additional sheets if necessary):”
Substantive
L
“Your evaluation of the management of the operation:”
Substantive
M
“□ Above Average
Substantive
H
June 2015
□ Average
□ Below Average (check one)”
FCIC 24040
Substantive
129
Exhibit 49
Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)
5
Acreage/Inspection Information (continued)
“You evaluation of the grove conditions:”
Substantive
Substantive
P
“□ Above Average
□ Average
“Action Recommended:”
Q
“□ Acceptance
N
O
6
□ Below Average (check one)”
Substantive
□ RMA RO Determined Yield Request □ Rejection”
Substantive
Required Signatures
A
“Inspector’s Printed Name, Signature and Date”
Substantive
B
“Inspector’s Code Number”
Substantive
C
“Date of Inspection”
Substantive
D
“Supervisor Printed Name, Signature and Date”
Substantive
E
“Supervisor Telephone Number”
Substantive
7
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
June 2015
FCIC 24040
130
Exhibit 50
Forage Production Underwriting Report
1
A
B
C
D
E
2
A
B
C
General Information
Substantive
“Applicant’s/Insured’s Name”
"State”
“County”
“Crop Year”
“Policy Number”
Substantive
Substantive
Substantive
Substantive
Crop Information
“Line Number”
Substantive
Substantive
Substantive
“Unit Number”
“FSA Farm/Tract/Field Number”
“Legal Description:”
___“Section:”
D
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
E
F
G
H
I
Substantive
Substantive
Substantive
“Acres”
“Share”
“Shareholder/Farm Name”
“Forage Plants per Sq. ft.?
(1) “Alfalfa”
(2) “Clover”
(3) “Other”
“Percentage of Ground Cover”
(1) “Alfalfa”
(2) “Clover”
(3) “Other”
“Crop Practice”
“Plants Other than Alfalfa”
“Uninsurable Acres”
“Acres Seeded with Another Crop”
“Remarks:”
Substantive
Substantive
J
K
L
M
N
3 Required Signatures
A
“Applicant’s/Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
June 2015
FCIC 24040
131
Exhibit 51
Hybrid Seed Yield Request
This request is to be completed by the Agent/AIP representative and submitted to the applicable RO
for approved yield requests. Refer to the CIH.
1
General Information
A
“Agent’s Name”
Substantive
B
C
D
“Agent’s Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
E
“AIP Name”
Substantive
F
G
H
I
J
K
L
“AIP’s Street and/or Mailing Address”
Substantive
"City and State”
Substantive
“Zip Code”
Substantive
“Seed Company Name”
Substantive
“Seed Company’s Street and/or Mailing Address”
Substantive
"City and State”
Substantive
“Zip Code”
Substantive
M
“Facility/Plant Location”
Substantive
N
“Seed Company Representative”
Substantive
2
Crop Information
Note: Create a table for the following columns
A
“Insured Name”
Substantive
B
“State and County of Insured Crop”
Substantive
C
“Number of Acres”
Substantive
D
“Hybrid Identification”
Substantive
3
Required Signatures
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
A
“AIP Representative’s Printed Name, Signature and Date”
Substantive
June 2015
FCIC 24040
132
Exhibit 52
Hybrid Seed Corn Yield History Report
1
General Information
A
B
C
D
“Seed Company”
Substantive
“Facility/Plant Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
E
“Facility/Plant Location”
Substantive
F
“Facility/Plant Representative”
Substantive
G
“Facility/Plant Telephone Number”
Substantive
2
A
Crop Information
“Hybrid Identification for ________________________”
Note: Code may be used.
Substantive
“Cross Type (check one)”
□ “Single”
B
C
□
□
□
“Modified Single”
“Three Way”
“Four Way”
“Planting Method (check one)”
□ “Straight Away”
□ “Split”
Substantive
Substantive
D
“Are the male (pollinator) rows inter-planted? □ Yes □ No”
Substantive
E
“For the above ____________, the expected or anticipated production yield is
____bushels per female acre.”
Substantive
F
“Yield must be on the basis as the yields provided below.”
Substantive
G
“Growing Area/Counties:”
Substantive
H
Note: Create a table with the following header row.
“ACTUAL YIELD DATA FOR ALL GROWERS ABOUR HYBRID
INDENTIFICATION AT THIS SPECIFIC PLANT LOCATION”
Note: Add to the table the following columns.
Substantive
I
“Non-Irrigated Production and Acreage”
Substantive
J
“Irrigated Production and Acreage”
Substantive
Note: Add to the table the following sub-columns.
K
“Total Female Field Production (Bu.)”
Substantive
L
“Total Female Acres Planted (Acres)”
Substantive
M
“Yield=Female Production/Female Acres Planted”
Substantive
N
“Crop Year”
Substantive
June 2015
FCIC 24040
133
Exhibit 52
Hybrid Seed Corn Yield History Report
2
O
P
Crop Information (continued)
Note: Include a section for the following statements.
“The field production data must be based on determinations obtained and calculated on
harvested production delivered to the plant prior to any production entering the seed
conditioning process. Hence, the field production data and the bushels per total female
acre yield are accepted by FCIC as harvested production leaving the field and delivered
to the seed company’s plant prior to entering any of the seed conditioning process (i.e.,
drying, shelling, screening, etc) only. The reported amount of harvested production
must be adjusted by you for moisture, shelling factor, and foreign material (I.e., husks,
stalks, etc.) as necessary. When applicable, the production data reported must include
the production figures determined for calculating any prior indemnified losses.”
“You must check one of the following numbers that describes the manner in which you
have determined/calculated the requested information and yield data.”
Substantive
Substantive
“For the purpose of determining the quantity of mature field production:
Q
3
(1) _____
Shelled corn was adjusted .12 percent for each .1 percentage point of
moisture to 15.0;
(2) _____
Ear corn was measured at 70 pounds of ear corn equaling 56 pounds (one
bushel) of shelled corn. The weight of ear corn required to equal one
bushel of shelled corn was increased 1.5 pounds for each percentage point
of moisture in excess of 14 percent; or
(3) _____
All records of harvested field seed production provided by the seed
company, were adjusted to a shelled corn basis of 15.0 percent moisture,
and 56-pound test weight.”
Substantive
Required Statement
Note: Certification statement above seed company representative signature:
A
4
A
“I certify that, to the best of my knowledge and belief, the information and data shown
for the above-identified hybrid on the seed company’s individual facility/plant location
is correct and the practices used to produce the stated results are continuing and
consistent to produce the same results.”
Substantive
Required Signature
“Seed Company’s Facility/Plant Representative’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
134
Exhibit 53
Hybrid Sorghum Seed Yield History Report
1 General Information
A “Seed Company”
“Facility/Plant Street and/or Mailing Address”
B
C "City and State”
D “Zip Code”
Substantive
Substantive
Substantive
Substantive
E
“Facility/Plant Location”
Substantive
F
“Facility/Plant Representative”
Substantive
G
“Facility/Plant Telephone Number”
Substantive
2
Crop Information
A
“Hybrid Identification for ________________________”
B
“Sorghum Seed Type:”
“□ Grain
□ Sudan
“Cross Type (check one)”
□ “Single”
□ “Modified Single”
C
Note: Code may be used. Substantive
□ Forage (check one)”
Substantive
Substantive
□
□
“Three Way”
“Four Way”
“Planting Method (check one)”
□ “Straight Away”
□ “Split”
Substantive
D
“Are the male (pollinator) rows inter-planted? □ Yes □ No”
E
“For the above ____________, the expected or anticipated production yield is
____bushels per female acre.”
F
“Yield must be on the basis as the yields provided below.”
Substantive
G
“Growing Area/Counties:”
Substantive
H
Note: Create a table with the following header row.
“ACTUAL YIELD DATA FOR ALL GROWERS ABOUR HYBRID
INDENTIFICATION AT THIS SPECIFIC PLANT LOCATION”
Note: Add to the table the following columns.
Substantive
I
“Crop Year”
Substantive
J
“Total Female Field Production (Bu.)”
Substantive
K
“Total Female Acres Planted (Acres)”
Substantive
L
“Yield=Female Production/Female Acres Planted”
Substantive
June 2015
FCIC 24040
Substantive
Substantive
135
Exhibit 53
Hybrid Sorghum Seed Yield History Report (Continued)
2
M
N
Crop Information (continued)
Note: Include a section for the following statements.
“The field production data must be based on determinations obtained and calculated on
harvested production delivered to the plant prior to any production entering the seed
conditioning process. Hence, the field production data and the bushels per total female
acre yield are accepted by FCIC as harvested production leaving the field and delivered
to the seed company’s plant prior to entering any of the seed conditioning process (i.e.,
drying, shelling, screening, etc) only. The reported amount of harvested production
must be adjusted by you for moisture, shelling factor, and foreign material (I.e., husks,
stalks, etc.) as necessary. When applicable, the production data reported must include
the production figures determined for calculating any prior indemnified losses.”
“You must check one of the following numbers that describes the manner in which you
have determined/calculated the requested information and yield data.”
Substantive
Substantive
“For the purpose of determining the quantity of mature field production:
(1) _____
Harvested seed production was adjusted .12 percent for each 0.1 percentage
point of moisture to 13.0; or
(2) _____
All records of harvested seed production provided by the seed company,
were adjusted to a basis of 13.0 percent moisture, and 56-pound test
weight.”
Substantive
O
3
Required Statement
Note: Certification statement above seed company representative signature:
A
4
A
“I certify that, to the best of my knowledge and belief, the information and data shown
for the above-identified hybrid on the seed company’s individual facility/plant location
is correct and the practices used to produce the stated results are continuing and
consistent to produce the same results.”
Substantive
Required Signature
“Seed Company’s Facility/Plant Representative’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
136
Exhibit 54
Added Land/New Crop/Practice/Type Request
The Added Land/New Crop/Practice/Type Request must be submitted to the applicable RMA RO
when cropland being added (or being planted to a new crop/P/T on land added during or after 2006) is
greater than or equal to 640 cropland acres but less than 2000 cropland acres and the insured request
use of the SA T-yield or the APH yield of an existing unit/database by the applicable deadline.
1
General Information
A
“Agent’s Name”
Substantive
B
C
D
“Agent’s Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
E
“Agent Code Number”
Substantive
F
Substantive
G
H
I
“Agent’s Telephone Number”
“Agent’s or AIP Authorized Representative’s Email”
“Insured Name (as shown on the Application)”
“Insured’s Street and/or Mailing Address
J
"City and State”
Substantive
K
“Zip Code”
Substantive
L
“County”
Substantive
M
“State”
Substantive
N
O
P
Q
“Policy Number”
“Crop Year”
“Identification Number”
Substantive
“Identification Number Type”
“Insured is:
□ Landlord
□ Operator
□ Owner/Operator”
Substantive
R
2
A
B
C
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Request Information
Note: Create a table with the following columns.
“Unit Number”
“FSA Farm/Tract/Field Number”
Note: Add the following footnote:
“An entry for the existing land and for the added land is needed for these columns.
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
D
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
June 2015
FCIC 24040
137
Exhibit 54
Added Land/New Crop/Practice/Type Request
2 Request Information (continued)
“Added Land Cropland Acres”
E
“Existing Unit Cropland Acres”
F
G “Request Type (E, S, or B**)”
H
I
J
K
3
A
B
Note: Add the following footnote (*, **):
“If added to existing unit, enter ‘E’, if a new separate optional unit, enter ‘S’; or if a new
basic unit, enter ‘B’”
“Crop(s)”
“Practice”
“Type”
Note: Create a checklist with the following instructions: “Submission Checklist: Check
all that apply”
□ “Documents”
□
□
D
□
E
□
F
□
G
□
4
Substantive
Substantive
Substantive
Substantive
Submission Checklist
C
H
Substantive
Substantive
Substantive
“Acceptable APH Databases and Production Reports for the current crop year.”
“Cropland acres, (i.e., FSA 578 or 156 EZ for the current or previous crop year), or
other documentation that indicates: cropland acres, legal description, ownership,
share, cash rent or lease agreement.”
“Aerial photos (farm boundaries clearly marked) with legal descriptions, FSN’s
and tract number as appropriate for both the added land and the existing land.
Include a highway map showing location of land for areas where section,
township, and range are not available.”
“APH Database from previous operator/tenant (only if the insured wishes APH
yields to be considered for productivity comparisons).”
“A copy of the page(s) of the county soil survey, with the exact location of the
field(s) clearly marked.”
“Other: (list)”
Note: Create a section for the following:
“If land is not being added for the current crop year, provide the month and year the
land was added, document the year the land was actually added to the operation and
number of cropland acres added.”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Agent’s Printed Name, Signature, Code Number and Date”
Substantive
5
Required Statements
B
“I hereby request an RMA RO underwriting review to determine the appropriate APH
calculation method(s) to calculate my insurance guarantee for land added to my
operation or for a new crop/P/T being planted on land added in 2006 or later crop year.
Insured crops for which this request is being made are listed in (list item number). I
understand that crop(s) not included on the request will use variable T-Yields, if
applicable.”
Certification Statement
Exhibit 2
C
Privacy Act Statement
Exhibit 3
Substantive
D
Nondiscrimination Policy Statement
Exhibit 4
Substantive
A
June 2015
FCIC 24040
Substantive
Substantive
138
Exhibit 55
Irrigated Practice Guidelines
The following guidelines are provided to enable insureds to properly report planted or perennial crop
acreage to be insured under the irrigated practice in order to receive maximum protection under their
crop insurance policy. It is very important that these guidelines be utilized to document whether, at the
time insurances attaches; there is a reasonable expectation of receiving adequate water to carry out a
good irrigation practice for acreage reported under the irrigated practice. The guidelines, in entirety,
are substantive and are to be given to the insured in administration of their crop insurance policy.
1
Definitions
Note: The following definitions are provided to facilitate a uniform understanding of the
standards and guidelines for the irrigated practice for planted or perennial crop acreage.
A
Adequacy of Irrigation Facilities— Irrigation facilities are considered adequate if it is
determined that, at the time insurance attaches, they will be available and usable at the
times needed and have the capacity to timely deliver water in sufficient quantities to
carry out a good irrigation practice for the acreage insured under the irrigated practice.
Substantive
Irrigation Equipment and Facilities – The physical resources, other than water, used to
B
regulate the flow of water from a water source to the acreage. This includes pumps,
valves, sprinkler heads, and other control devices. It also includes pipes or pipelines
which: (1) are under the control of the insured or (2) routinely deliver water only to
acreage which is owned or operated by the insured. A center pivot system is considered
irrigation equipment and facilities.
Substantive
C
Irrigation Water Supply – The water source and means for supplying irrigation water,
without regard to the equipment or facilities. This includes the water source and dams,
canals, ditches, pipelines, etc., which contain the water for movement from the source to
the acreage and (1) are not under the control of the insured or (2) routinely deliver water
to acreage in addition to that which is owned or operated by the insured. It DOES NOT
INCLUDE any irrigation equipment or facilities.
Substantive
D
Water Source – The source from which water is made available. This includes wells,
lakes, reservoirs, streams, aquifers, etc.
Substantive
June 2015
FCIC 24040
139
Exhibit 55
Irrigated Practice Guidelines (Continued)
2
Guidelines for Annual or Perennial Crop Acreage
Note: To report planted or perennial crop acreage insured under the irrigated practice,
the following requirements must be met.
Insured must be able to demonstrate, to the approved insurance provider’s satisfaction,
that adequate facilities and water existed, at the time insurance attached, to carry out a
good irrigation practice for the insured crop. Some factors that the insured should be
able to document and/or demonstrate would include, but are not limited to the following:
A
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
B
C
D
Water source history, trends, and forecasting reliability
Water supply availability and usage.
Pump efficiency and capacity
Water requirements (amount and timing) of all crops to be irrigated;
Water rights (primary, secondary, urban versus agricultural use, etc.)
Contingency plans to handle shortages
Acres to be irrigated
Ownership of the water (state or federal versus landowner)
Meters, measuring devices and methods used
Soil types, soil moisture levels, and pre-plant irrigation needs
Water conservation methods, devices used, and plans utilized (if applicable)
Past crop planting history and tillage methods
Quantity and quality of the water supply
Supplemental water availability and usage (including return flow)
Recommendations from local County Extension Service (CES) or National Resource
Conservation Service (NRCS), and other source recognized by CES or NRCS to be
an expert in this area) regarding irrigation and crop production
Factors considered in reporting acreage to be insured under an irrigated practice.
Information the insured knew (or should have known) and when the insured knew (or
should have known) such information pertinent to supporting a good irrigation
practice.
Insured should have reasonable expectations, at the time coverage begins, of receiving
adequate water to carry out a good irrigation practice. If the insured knew or had reason
to know that the amount of his/her irrigation water may be reduced before coverage
begins, no reasonable expectation existed.
Decreased water allocation resulting from the diversion of water for environmental or
other reasons is not an insurable cause of loss unless the diversion is made necessary due
to an insured cause of loss.
Insured needs to be able to document and/or demonstrate good irrigation practices,
showing the application of adequate water in an acceptable manner at the proper times to
allow for normal crop production, measured as the Approved APH yield for the unit.
June 2015
FCIC 24040
Substantive
Substantive
Substantive
140
Exhibit 55
Irrigated Practice Guidelines (Continued)
2
Guidelines for Annual or Perennial Crop Acreage (continued)
The determination of the adequacy of water will be based upon:
E
(1)
The water available (at the time insurance attaches) from the irrigation water
supply, soil moisture levels, and, as applicable, snow pack storage levels;
(2)
Supplementary precipitation which would normally be received, after insurance
attaches, during the period that a good irrigation practice is normally carried out.
Substantive
Consideration will also be given to the factors identified in Item A above, including
(3) the legal entitlement or rights to water.
F
Insured must demonstrate that they have the physical resources, other than water, used to
regulate the flow of water from a water source to the acreage. This includes pumps,
valves, sprinkler heads, and other control devices. It also includes pipes or pipelines
which (1) are under the control of the insured or (2) routinely deliver water only to
acreage which is owned or operated by the insured. A center pivot system is considered
irrigation equipment and facilities.
Substantive
G
Irrigation facilities are considered adequate if it is determined that, at the time insurance
attaches to planted or perennial acreage, they will be available and usable at the times
needed and have the capacity to timely deliver water in sufficient quantities to carry out a
good irrigation practice for the acreage insured under the irrigated practice.
Substantive
H
If the acreage fails to qualify for insurance under the irrigated practice, it will result in
such acreage being insured under a practice other than irrigated. If no other appropriate
practice is available for the acreage, insurance will not be considered to have attached on
the acreage.
Substantive
I
Failure to carry out a good irrigation practice on acreage properly insured under the
irrigated practice will result in an appraisal for uninsured causes against such acreage,
unless the failure was caused by unavoidable failure of the irrigation water supply after
insurance attached or failure or breakdown of the irrigation equipment or facilities due to
an insured cause of loss provided all reasonable efforts to restore the irrigation
equipment facilities to proper working order within a reasonable amount of time were
taken by the insured, unless the AIP determines it is not practical to do so. Cost will not
be considered when determining whether it is practical to restore the equipment or
facilities.
Substantive
If a loss is evident, acreage reported as an irrigated practice that qualified as an irrigated
practice at the time insurance attached cannot be revised to a non-irrigated practice after
the acreage reporting date even if liability stays the same or decreases, even if the insured
never applied any water.
J
Insureds are required to keep separate production records for acreage insured under the
irrigated practice from acreage insured under a practice other than irrigated (or with no
practice applicable) and uninsured acreage.
June 2015
FCIC 24040
Substantive
141
Exhibit 55
Irrigated Practice Guidelines (Continued)
3
Guidelines for Prevented Planting Coverage
A
Insureds may be able to receive a prevented planting payment for acreage historically
grown under an irrigated practice if there is not a reasonable expectation of having
adequate water (due to an insured cause of loss occurring in the prevented planting
insurance period) on the final planting date (or within the late planting period if the
insured elects to try to plant the crop) to carry out an irrigated practice, provided all other
prevented planting provisions have been met.
Substantive
B
Insureds are expected to be prepared to provide documentation of the factors which were
considered in reporting that there was no reasonable expectation of receiving adequate
irrigation water for the acreage reported as prevented planting under an irrigated practice.
Substantive
C
Acreage historically grown under an irrigated practice for which the insured had no
reasonable expectation of having adequate irrigation water by the final planting date (or
within the late planting period, if applicable), may be eligible for an irrigated prevented
planting payment even if the acreage could have been planted with a non-irrigated
practice and the producer elects not to plant.
Substantive
June 2015
FCIC 24040
142
Exhibit 56
Loss Adjustment Certification Form
This form must be titled “Certification Form” and should be completed and returned by the insured to
the AIP within five days (or within the timeframe specified by the AIP) after all acreage in the unit has
been put to another use, completion of replanting on the unit for replanting payments, or any action to
which is certified as indicated by the form*. See the LAM for form completion instructions. The
following statement must appear below the form title:
“Complete and mail this form within (5) days (or within the timeframe specified by your Approved
Insurance Provider) after: (1) all acreage in the unit has been put to another use, (2) completion of
replanting on the uniting for replanting payment, (3) For nursery, all Zero Market Value (ZMV) plants
on the unit have been destroyed, or (4) any action to which you have certified as stated on this form.”
1
A
B
C
D
E
2
General Information
Note: The following statement must appear below the form title:
“Complete and mail this form within (5) days (or within the timeframe specified by your
Approved Insurance Provider) after:
(1) All acreage in the unit has been put to another use,
(2) completion of replanting on the uniting for replanting payment,
For nursery, all Zero Market Value (ZMV) plants on the unit have been destroyed,
(3)
or
(4) Any action to which you have certified as stated on this form.”
“Insured’s Name”
“Policy Number”
“Date Originated”
“Return To: (include Adjuster’s Name, AIP Name, Mailing Address, City, State, Zip
code)”
Substantive
Substantive
Substantive
Substantive
Substantive
Crop Information
A
“Crop Year”
Substantive
B
“Crop”
Substantive
C
“FSA Farm/Tract/Field Number”
Substantive
D
“Unit Number”
Substantive
E
“Unit Acres”
Substantive
3
Replant/Other Uses of Acreage Information
B
Note: Added the following Statement above the table.
“Replant, destruction, or other use of acreage (plants for nursery) identified was
completed on the date(s) shown.”
Note: Create a table with the following columns in the exact order listed below from left
to right.
“Field Identification Symbol (Plant Location for Nursery)”
Substantive
C
“Intended Use”
Substantive
D
“Acres (Number of Plants for Nursery)”
Substantive
E
“Actual Use”
Substantive
F
“Acres (Number of Plants for Nursery”
Substantive
G
“Date”
Substantive
A
June 2015
FCIC 24040
Substantive
143
Exhibit 56
Loss Adjustment Certification Form (Continued)
3
Replant/Other Uses of Acreage Information (continued)
H
“Replant Cost per Acre”
Substantive
I
“Practice/Type”
Substantive
Note: Create one row for the following:
J
“Totals”
Substantive
Note: Allow additional space for or provide a separate form for
K
“Remarks:”
Substantive
Note: Insert the following footnote
L
“Refer to the crop policy qualifications for replanting payments.”
Substantive
Example:
“Replant, destruction, or other use of acreage (plants for nursery) identified was completed on the
date(s) shown.”
Field ID
Intended
Use
Acres
Actual
Use
Acres
Date
Replant
Costs
per Acre
Practice/Type
or Class
Substantive
M
Totals:
Remarks
*Refer to the crop policy qualifications for replanting payments.
4
Required Loss Adjustment Statements
Note: Include a list of the following required certification statements. The AIP has the
discretion of either creating an individual certification form and affixing one of the
appropriate loss adjustment statements below, as required by procedure, or creating the
multiple statement list on a single form as shown below, and providing instruction to the
loss adjuster/AIP representative. All statements are Substantive and must appear in its
entirety. The AIP is not to instruct the loss adjuster/AIP representative to handwrite any
of the statements below to a form that the insured must sign. The statements are to
appear either as a single statement on the certification form; therefore, generating
multiple certification forms, or as a general certification form containing a checklist of
the statements listed below.
If a list is created the loss adjuster/AIP representative must check those applicable
required statements in accordance with loss adjustment procedures.
June 2015
FCIC 24040
144
Exhibit 56
Loss Adjustment Certification Form (Continued)
4
Required Loss Adjustment Statements (continued)
□
“I certify that the damaged acreage cannot be mechanically harvested with normal
harvest equipment and will not be harvested. If the crop is harvested after this
certification, I understand I may be subject to the misrepresentation provisions in
the crop insurance policy.”
□
“I certify that the acreage in Unit [INSERT UNIT NUMBER] will not be
harvested and that the acreage will be put to the use as stated in [insert appropriate
item location] when there is sufficient soil moisture. I understand the acreage will
not be reappraised by the AIP.”
A
□
5
Substantive
“I certify that the damaged acreage that cannot be mechanically harvested with
normal harvest equipment will not be harvested and if the acreage is gleaned it will
be gleaned by the organization shown in the narrative of the claim form (or other
USDA approved charitable organizations) and the insured will not receive any
compensation from the organization. If I harvest the crop after this certification
or receive compensation from the charitable organization, I understand I may be
subject to the misrepresentation provisions in the crop insurance policy.”
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Substantive
D
“I understand that the information on this form may be
used for processing the claim which I previously signed.
Exhibit 4
Note: Include this
statement above the
insured’s signature,
6
Substantive
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”
Substantive
7
Other Information
Note: Include the following checklist and title “For Office Use Only”. This checklist
should appear next to the Loss Adjuster’s Signature.
□ “Accepted”
A
□
□
June 2015
“Rejected”
Substantive
“Second Inspection”
FCIC 24040
145
Exhibit 57
Loss Adjustment Self-Certification Replant Worksheet
This form must be titled “Self-Certification Replant Worksheet”. This worksheet can be used only: (1)
when the AIP authorizes its use, (2) for authorized crops listed in the LAM, and (3) when the acreage
of the authorized crop to be replanted is 50 acres or less for a unit and the unit acreage qualifies for a
replanting payment in accordance with the policy/endorsement replanting provisions. See the LAM
for further completion instructions.
1
General Information
Note: The following statement must appear below the form title:
A
“The Self-Certification Replant Worksheet may be used when the acreage to be replanted
is 50 acres or less for the unit. Per the policy provisions, in order to qualify for a replant
payment, the number of acres to be replanted must be at least the lesser of 20 acres or
20% of the insured planted acreage for the unit (as determined on the final planting date
or within the late planting period if a late planting period is applicable). The potential for
the acres to be replanted must not exceed the amount stated in the crop policy. A replant
payment may be made only once on the acreage in the same location for the same crop
year.
Substantive
Complete and mail this form within five (5) days (or within the timeframe specified by
your Approved Insurance Provider) after completion of replanting on the unit for
replanting payment. If the crop provisions specify a replanting payment is based on actual
cost, attach copies of receipts for replanting expenses actually incurred for the replanted
acreage (those expenses you actually paid or are liable for). (Refer to your crop policy
qualification for replanting payments).”
B
“Insured’s Name”
“Policy Number”
“Claim Number”
Substantive
Substantive
Substantive
C
D
2 Crop Claim Information
A “Crop Year”
B “Crop”
C “Share”
D “Unit Number”
E “FSA Farm/Tract/Field Number”
F “Unit Acres”
G “Replanted Acres”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Legal Description:”
___“Section:”
H
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
I
“Cause of Damage”
June 2015
Substantive
FCIC 24040
146
Exhibit 57
Loss Adjustment Self-Certification Replant Worksheet (Continued)
2 Crop Claim Information (continued)
J “Date of Damage”
K “Original Plant Date”
L “Replant Date”
Substantive
Substantive
Substantive
Note: Create an area for a field diagram allowing substantial room for a sketch of the
field and replant acreage. The AIP has discretion on whether to provide a separate form
for this sketch.
M “Field Diagram”
Substantive
Note: Add the following instruction to the field diagram:
N
“Draw the field where the crop is planted. Shade the area actually replanted”
Substantive
Example:
NonSubstantive
O
P
“Indicate the practice/type utilized”
□
□
□
□
Q □
□
Note: Provide a checklist with two
columns titled “Original” and “Replant” of
the following practice/types:
Substantive
“Drilled”
“Broadcast”
“Airplane-seeded”
“Rowed”
“Dry Bean Type”
“Tillage Method”
Substantive
Note: Provide instruction to write-in
tillage method used for original and
replant acreage.
Note: Provide instruction to write in a
practice/type if not listed.
Note: Provide instruction to answer the following questions:
□
R
S
“Other”
“My yield potential for acres to be replanted is _____ per acre.”
Substantive
“Is damage on your farm similar to other farms in the area? Yes □ No □”
Substantive
June 2015
FCIC 24040
147
Exhibit 57
Loss Adjustment Self-Certification Replant Worksheet (Continued)
2
T
3
A
B
C
D
Crop Claim Information (continued)
Note: Instruct that the Insured’s total actual costs to replant acreage includes only the
dollar amount the insured has paid or is liable to pay.
“The following represents my actual replant costs as:
___
Landlord
___
Tenant
___
Owner/Operator”
Substantive
Other Information
Note: Provide instruction for the reviewer to check when attached or accompanies the
Self-Certification Replant Worksheet.
“Special Report □”
“Reviewer’s Remarks”
“Reviewer Code and Date”
Note: Provide instruction for the reviewer to enter “O.K.” if the reviewer verifies the
field or subfield was initially planted timely and that the number of acres actually
replanted agrees with the entry of the total number of replanted acres.
“Actual/Replant Acres”
Substantive
Substantive
Substantive
Substantive
Note: Provide instruction for the reviewer to enter “O.K.” if the reviewer verifies the
date of damage agrees with the date entered above.
E
“Date of Damage”
Substantive
Note: Provide instruction for the reviewer to enter “O.K.” if the reviewer verifies that
the type or practice used agrees with the type/practice entry above..
F
“Cause of Damage”
Substantive
G
“Replant Practice”
Substantive
“Did acreage appear to quality? Yes □ No □”
Note: Provide instruction for the reviewer to enter “O.K.” if the reviewer verifies that
the insured or the insured’s authorized representative that the total cost incurred by the
insured for the replanting operation is the same as entered above.
“Actual Cost”
Substantive
H
I
June 2015
FCIC 24040
Substantive
148
Exhibit 57
Loss Adjustment Self-Certification Replant Worksheet (Continued)
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
“I understand the certified information will be used to
determine my replanting payment, if any, for damage to
the above crop. I also understand that this Worksheet and
Note: Include this
supporting papers are subject to audit and approval by the
statement above the
insurance provider and that my signature herein
insured’s signature.
authorizes the insurance provider to process a replanting
payment in accordance with the terms of my insurance
contract.”
Substantive
D
5
Substantive
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
149
Exhibit 58
Loss Adjustment Claim Checklist
This form must be titled “Claim Checklist”. It is recommended that the AIP provides this or a similar
checklist to loss adjusters for completion during each loss inspection. The AIP has the discretion to
develop a similar checklist that been modified to fit their region and the crops insured. See the LAM
for more information and completion instruction regarding this form.
1
General Information
A
“Insured’s Name”
B
“Policy Number”
C
“Claim Number”
D
“Crop(s)—Units”
2
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
Claim Information
Yes
No
Create a checklist for the following questions, include a Yes � No � option
at the end of each question with instruction to check one and explain, as
appropriate.
A
□
□
(1)
“Insured Present”
B
□
□
(2)
“Insurable Entity Verified”
C
□
□
(3)
“Timely Notice”
D
□
□
(4)
“Share Verified”
E
□
□
(5)
“Companion Contract Verified (if applicable)”
F
□
□
(6)
“Legal Description Verified”
G
□
□
(7)
“Practice(s) Insurability Verified”
H
□
□
(8)
“Insurable Type/Variety Verified”
I
□
□
(9)
“Unit/Unit Division Verified”
J
□
□
(10) “Planting Dates Verified”
K
□
□
(11) “Risk Area Verified”
L
□
□
(12) “Insurable Causes of Loss”
M
□
□
(13) “Similar Damage”
N
□
□
(14) “Reasonable APH”
O
□
□
(15) “Insurable Acreage”
June 2015
FCIC 24040
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
150
Exhibit 58
Loss Adjustment Claim Checklist
2 Claim Information (continued)
P
□
□
(16) “Sharing Interests
Q
□
□
(17) “Options/Endorsements”
R
□
□
(18) “Review Previous Report”
S
□
□
(19) “Previous Appraisals”
T
□
□
(20) “Quality Adjustment Eligibility Verified”
U
□
□
(21) “Acreage Determined/Method”
V
□
□
(22) “Acreage Replanted”
W
□
□
(23) “Replanting Payment”
X
□
□
(24) “Certification Form”
Y
□
□
(25) “Sold Production Verified”
Z
□
□
(26) “Farm-Stored Production Verified”
AA
□
□
(27) “Commingled Production”
BB
□
□
(28) “Fed Production Verified”
CC
□
□
(29) “Other Names/Entities for Production Verified”
DD
□
□
(30) “All Production Accounted For”
EE
□
□
(31) Unusual/Controversial Circumstances”
FF
□
□
(32) “Reviewed Completed Claim with Insured or Insured’s
Representative”
GG
□
□
(33) “Obtained Signatures”
HH
□
□
(34) “Second Crop Acreage”
II
□
□
(35) “Signatures”
JJ
□
□
(36) “Other”
3
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
NonSubstantive
Required Signatures
Note: Obtaining a signature is optional unless otherwise instructed by the AIP; however,
it is recommended that adjuster’s sign the form to facilitate necessary follow-up actions.
A
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”
June 2015
FCIC 24040
NonSubstantive
151
Exhibit 59
Loss Adjustment Simplified Claims Qualification Process and Notice of Loss
AIP and insured participation in SCP is voluntary. All SCP claims must be completed on a form
developed by the AIP that captures all the required loss information from the insured. The AIP is also
responsible for developing comprehensive completion instructions for the insured to complete the SCP
form. See the LAM for further information.
1
A
B
C
D
E
F
G
H
I
J
K
L
M
General Information
“Insured’s Name”
“Policy Number”
“Agent Name”
Substantive
Substantive
Substantive
“Insured’s Telephone Number”
“Insured’s Street and/or Mailing Address
Substantive
Substantive
"City and State”
Substantive
“Zip Code”
Substantive
“Crop (only one per form)”
Substantive
“Crop Year”
Substantive
“County Where Crop Is Grown (only one per form)”
Substantive
“State Where the Crop Is Grown (only one per form)”
Substantive
“Non-Loss (N-L) Units and Establish Production Per Acre”
Substantive
“Loss Unit Number”
Substantive
“Cause of Loss”
N
(1)
“Primary Cause/ Percentage”
(2)
“Secondary Cause/ Percentage”
Substantive
“Date of Damage”
O
P
Q
R
S
(1)
“Primary Cause Date of Damage”
(2)
“Secondary Cause Date of Damage
“Harvest Completion Date”
Substantive
Substantive
“Companion Contract Yes □ No □””
“Assignment of Indemnity Yes □ No □”
“Transfer of Right to an Indemnity Yes □ No □”
June 2015
Substantive
FCIC 24040
Substantive
Substantive
152
Exhibit 59
Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)
2
Loss Information
Yes
A
□
No
Note: Create a checklist with the following questions and instruct to answer
Yes □ or No □, allow additional space for explanation where applicable.
All questions are “Substantive”
□
(1) “Has all acreage of the loss units listed in [INSERT LOCATION ON
THE FORM THE LOSS UNIT NUMBER INFORMATION IS
REFERENCED] been harvested? If no, list the unit numbers(s) for
which “No” applies.”
(2)
B
□
□
(3)
C
□
□
(4)
D
E
F
□
□
□
□
□
(8)
I
□
□
June 2015
Substantive
“If you answered no to the above question, do you anticipate loss units
for any crop not listed in [INSERT LOCATION ON THE FORM THE
LOSS UNIT NUMBER INFORMATION IS REFERENCED] for this
crop year?
Substantive
“Do you have third party written verification (i.e., summary
/settlement sheets) available for 100 percent of the production from all
unites listed in [INSERT LOCATION ON THE FORM THE LOSS
UNIT NUMBER INFORMATION IS REFERENCED] above? (This
must include both landlord and tenant shares, when applicable).
□
□
“Have you completed harvest of all insurable acreage for all crops on
your policy? (This includes the crop you listed above as well as any
other crop you may have on your policy). If no, list the crops not
harvested.”
(6)
□
□
Substantive
“Has any production from any acreage from the units listed in [insert
location on the form the loss unit number information is referenced]
Substantive
been farm stored, fed to livestock, or saved for seed? If no, list the unit
number(s) for which “No” applies.
□
H
“Has all of the production from the loss unit(s) listed in [INSERT
LOCATION ON THE FORM THE LOSS UNIT NUMBER
INFORMATION IS REFERENCED] been sold or commercially
stored? If you answered no, list the applicable unit number for which
“no” applies.”
(5)
(7)
G
Substantive
(9)
“Is the damage for the loss units listed in [INSERT LOCATION ON
THE FORM THE LOSS UNIT NUMBER INFORMATION IS
REFERENCED] similar to other farms in the area? If no, list the
unit(s) for which “No” applies and explain:”
“Are you or any member of your household directly associated with
the Federal Crop Insurance program (i.e., agent, agency owner, loss
adjuster, FCIC employee, insurance provider employee or
contractor)?”
“Was all acreage of your insured crop(s) in the county, in which you
have a share, reported by you on your acreage report? If no, list the
unit or location where the acreage was not reported.”
FCIC 24040
Substantive
Substantive
Substantive
Substantive
153
Exhibit 59
Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)
2 Loss Information (continued)
Yes
No
Note: Create a checklist with the following questions and instruct to answer
Yes □ or No □, allow additional space for explanation where applicable.
All questions are “Substantive”
(10) “On the specific loss unit(s) listed in [INSERT LOCATION ON THE
FORM THE LOSS UNIT NUMBER INFORMATION IS
REFERENCED] above, is your Summary of Coverage for:
J
3
□
(a)
Your share? If no, list the unit(s) and explain:
(b)
“The legal description(s) and/or FSA farm serial number? If no, list
the unit(s) for which “No” applies.”
(c)
“The practice actually carried out by you (i.e., If you reported your
practice is irrigated, was water applied at the proper time and rate)? If
no, list the unit(s) for which “No” applies,
□
(d)
The type or variety (if applicable)? If no, list the unit(s) for which
“No” applies and enter the correct type or variety for each unit listed.
(e)
The total acreage for each loss unit listed in [INSERT LOCATION
ON THE FORM THE LOSS UNIT NUMBER INFORMATION IS
REFERENCED] If no, list the unit(s) for which “No” applies.”
(f)
Will the acreage (if measured or re-measured) be within five (5)
percent of what you reported on your acreage report? If no, list the
unit(s) for which “No” applies.
Substantive
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
June 2015
FCIC 24040
154
Exhibit 59
Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)
3 Required Statements (continued)
Simplified Claims Qualification Process Statement
“This form serves as written verification of your notice of loss and as an aide in
determining qualified insureds for the SCP. We may rely on the information you provide
on (or attach to) this form in making material determinations in the preparation of your
claim.
D
Once this completed Notice of Loss form and supporting documentation has been
received by [INSERT AIP NAME], it will be determined whether or not your claim
qualifies for the SCP. If it does qualify, the appropriate claim for indemnity form(s) will
be prepared and may be sent to you for your signature if the insurance provider
determines when reviewing this information with you that a correction is needed.
Otherwise, the signature on this SCP form will serve as the signature for each Claim for
Indemnity form to which this information was transferred, and a copy will be mailed to
you. The claim form(s) will contain all the necessary data and production information to
complete your claim. If qualified, you will have your claim processed in the most
expedient manner possible. You will not need to wait for an adjuster. The SCP is
subject to an infield review for compliance with established policies and procedures. If
any of the unit(s) listed in [INSERT LOCATION ON THE FORM THE LOSS UNIT
NUMBER INFORMATION IS REFERENCED] does not qualify for SCP, you will be
contacted by a claims representative to set up an appointment to adjust your loss on that
or all units listed above.”
Substantive
Supporting documentation must be attached to this form and delivered to the address
provided by your agent or insurance provider. You must attach either a copy of
settlement sheet(s), summary sheet(s), or similar third party ledger(s) that accounts for all
production from any crop unit you have listed above. Individual load tickets will not
qualify. Individual loads on any settlement/summary sheet(s) must be clearly marked to
indicate which unity they came from. If you have FSA or similar measurement service
for determining acreage, such as Global Positioning Systems, remote sensing devices,
etc., for the current crop year, please attach copies and indicate who made the acreage
measurement. If you have met the requirements of precision farming and want to use
those records to establish production, you must attach yield maps and planting and
harvesting summary repots generated from the precision farming technology system.
The per unit acreage used in calculating any indemnity will be the lesser of your reported
acres or your actual planted acres. In all cases you must attach copies of maps
identifying each field, crop and acreage by loss unit.”
4
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“AIP Verifier’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
155
Exhibit 60
Loss Adjustment Notice of Damage or Loss
The Notice of Damage or Loss is used to record loss and provide notice to the AIP for planted
acres. These standards may be combined with the Notice of Prevented Planting if the form is
utilized to record the notice. See the LAM for form completion instructions.
1
A
B
C
D
E
General Information
“Insured’s Name”
“Insured’s Street and/or Mailing Address
Substantive
"City and State”
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
NonSubstantive
Substantive
NonSubstantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
F
“Best Time to Contact: [INSERT TIME] am/pm”
G
“Policy Number”
H
“Claim Number:
I
J
K
L
M
2
A
B
C
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
“Agent’s Telephone Number”
D
Crop Information
“Crop Year”
Substantive
“Crop”
Substantive
“Unit Number”
Substantive
NonSubstantive
“Acres”
“Legal Description:”
___“Section:”
E
Note: See associated required statement
in item 4D below. This statement is
Substantive when this item appears on the
form.
___“Township:”
___“Range:”
NonSubstantive
___“Other Land Identifier (e.g., Spanish
land grants, metes and bounds, etc.):”
F
“Date of Damage”
Substantive
G
“Cause of Damage”
H
“Estimated Production”
I
“Expected Harvest Date”
Substantive
NonSubstantive
NonSubstantive
June 2015
FCIC 24040
156
Exhibit 60
Loss Adjustment Notice of Damage or Loss (Continued)
3
Notice Information
Include the following instruction: “Refer to the applicable Basic Provision or Crop
Provisions for more information regarding damage or loss notice reporting requirements.”
“This is a notice of:”
A
B
□
□
□
NonSubstantive
“Damage Only: At this time, it appears that the damage will exceed the guarantee.”
“Probable Loss’
“Immediate Inspection Requested. If checked, explain why in the comments
section”
“If you have less than 100% share, is the other share insured under a Federal crop
insurance program? If so, list the person’s name, AIP, and policy number, if known.”
Substantive
Substantive
“Insured Intends to: (Check One)
C
D
E
□
□
□
□
□
□
□
□
□
□
□
(1)
“Harvest’
(2)
“To Chop/Silage”
(3)
“Leave for Cover”
(4)
“Destroy”
(5)
“Plant to Another Crop:
(6)
“Pasture”
(7)
“Hay”
(8)
“Direct Market Crop”
(9)
“Replant”
Substantive
(10) “Unknown”
(11) “Other, explain in the comments section”
“If the Insured intends to replant and a replanting payment is applicable, is the acreage
greater than 50 acres of the unit? Yes □ No □ (Check One)”
“I request authorization to commingle production from two or more units or commingle
production between insured and uninsured acreage within the same structure and to use
my load records, structure markings, or combine monitor records to determine production
between units or production from insured/uninsured acreage. Do you agree to follow your
insurance provider’s written criteria and instructions to do this? Yes □ No □ (Check
One)”
June 2015
FCIC 24040
Substantive
Substantive
157
Exhibit 60
Loss Adjustment Notice of Damage or Loss (Continued)
4
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
D
“I understand that authorization for
commingling production must be received
from my approved insurance provider before
production can be commingled. I also
understand that if authorization is given, my
approved insurance provider will provide (or
has provided) written criteria and instructions
for the use of load or combine monitor records
to separate such production, and if I fail to
follow all instructions, my optional unit
structure will be collapsed.”
Note: Include instruction for insured
to initial this statement.
NonSubstantive
E
“I am an agent, employee, or contractor
affiliated with the Federal crop insurance
program. Yes □ No □ (Check One)”
Note: Include instruction for insured
to complete.
Substantive
5
A
B
Required Signatures
“Insured’s Printed Name, Signature and Date of Notice”
Note: Substantive only when the
“Agent’s Printed Name, Signature, Code
agent/AIP receives the notice from
Number and Date of Notice”
the insured by phone or e-mail.
June 2015
FCIC 24040
Substantive
Substantive
158
Exhibit 61
Loss Adjustment Notice of Prevented Planting
The Notice of Prevented Planting is used to record loss and provide notice to the AIP for acres
that were prevented from being planted. These standards may be combined with the Notice of
Damage or Loss if the form is utilized to record the notice. See the LAM for form completion
instructions.
1
A
B
C
D
E
General Information
“Insured’s Name”
“Insured’s Street and/or Mailing Address
Substantive
"City and State”
Substantive
“Zip Code”
Substantive
“Insured’s Telephone Number”
Substantive
NonSubstantive
Substantive
NonSubstantive
Substantive
Substantive
Substantive
Substantive
Substantive
F
“Best Time to Contact: [INSERT TIME] am/pm”
G
“Policy Number”
H
“Claim Number:
I
J
K
L
M
2
A
B
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
“Agent’s Telephone Number”
Substantive
Crop Information
“Crop Year”
Substantive
“Crop”
Substantive
NonSubstantive
NonSubstantive
C
“Unit Number”
D
“Acres”
“Legal Description:”
___“Section:”
E
Substantive
___“Township:”
___“Range:”
___“Other Land Identifier (e.g., Spanish land grants, metes and bounds, etc.):”
F
“Date of Damage”
Substantive
G
“Cause of Damage”
Substantive
June 2015
FCIC 24040
159
Exhibit 61
Loss Adjustment Notice of Prevented Planting (Continued)
3
A
Notice Information
Include the following instruction: “Refer to the applicable Basic Provision or Crop
Provisions for more information regarding damage or loss notice reporting
requirements.”
“If you have less than 100% share, is the other share insured under a Federal crop
insurance program? If so, list the person’s name, AIP, and policy number, if known.”
Substantive
Substantive
“Insured Intends to: (Check One)
B
4
□
□
□
□
□
□
□
(1) “Plant a Cover Crop”
(2)
“Destroy”
(3)
“Plant to Another Crop:
(4)
“Graze (Only After November 1)”
(5)
“Hay (Only After November 1)”
(6)
“Unknown”
(7)
“Other, explain in the comments section”
Substantive
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
D
“I am an agent, employee, or contractor
affiliated with the Federal crop insurance
program. Yes □ No □ (Check One)”
5
A
B
Note: Include instruction for insured
to complete.
Substantive
Required Signatures
“Insured’s Printed Name, Signature and Date of Notice”
Note: Substantive only when the
“Agent’s Printed Name, Signature, Code
agent/AIP receives the notice from
Number and Date”
the insured by phone or e-mail.
June 2015
FCIC 24040
Substantive
Substantive
160
Exhibit 62
Growing Season Inspection Report
Growing Season Inspections (GSIs) are done as a part of quality assurance and may be done in
conjunction with a Pre-Harvest Inspection. See the LAM for form completion instructions.
1
A
B
C
D
E
F
G
H
I
J
K
L
General Information
“Insured’s Name”
“Policy Number”
“Crop Year”
Substantive
Substantive
Substantive
“Crop”
Substantive
“Unit Number”
Substantive
“Acres”
Substantive
“Share”
Substantive
“Practice”
Substantive
“Appraised Potential”
Substantive
“Companion Contract Yes □ No □””
“Field Identification”
Substantive
“Planting/Replanting Date”
Substantive
Note: Provide space to enter both dates if
applicable and to add additional dates by
field.
M “Narrative”
2 Required Questions
Substantive
Substantive
A
“What kind of tillage methods has the insured carried out?”
Substantive
B
“What kind of weed control practices are being carried out?”
“Has current soil test(s) been taken on any of the insured acreage? If yes, record the date
of test and test results. If all of the information cannot be obtained, explain.”
“How does the crop inspected compare with those in the general area? If the condition
of the crop being inspected differs from those in the general area, document differences.”
“What fertilizer program is being followed? Record the type of program used. If all of
the information cannot be obtained, explain.”
“What insecticide/pesticide program is being followed? Record the type of program
used. If all the information cannot be obtained, explain.”
“Weather Conditions?”
Substantive
C
D
E
F
G
H
I
J
K
L
M
Substantive
Substantive
Substantive
Substantive
Substantive
“Is an irrigated practice insured on the crop unit being inspected?
Substantive
“Type of Irrigation System and Average Times Used”
Substantive
“Is the irrigation system adequate? Yes □ No □ (Check One). If no, explain.”
Substantive
“Is the irrigation water adequate? Yes □ No □ (Check One). If no, explain.”
“Should the insured’s farming operation be inspected at a later date? Yes □ No □
(Check One). Please explain why or why not.
“Comments”
June 2015
FCIC 24040
Substantive
Substantive
Substantive
161
Exhibit 62
Growing Season Inspection Report (Continued)
3
Required Statements
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
6
Required Signatures
A
“Insured’s Printed Name, Signature and Date”
Substantive
B
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”
Substantive
June 2015
FCIC 24040
162
Exhibit 63
New Producer Certification
Form is completed when an insured initially requests new producer status for APH Database
Establishment. This form is non-substantive; however, if AIPs elect to use this form, all elements are
substantive.
1
Insured Information
A
“Insured’s Name”
Substantive
B
C
D
E
F
G
H
I
J
K
L
2
“Street and/or Mailing Address”
"City and State”
Substantive
Substantive
“Zip Code”
Substantive
“Telephone Number”
Substantive
“Policy Number”
Substantive
“State and County”
“Crop Year”
“Identification Number”
Substantive
Substantive
Substantive
“Identification Number Type”
“SBI Identification Number”
“SBI Identification Number Type”
Substantive
Substantive
Substantive
A
B
3
Crop Information
“Crop”
“Practice/Type”
Substantive
Substantive
New Producer Certification Statement
“I certify that I have not produced the insured crop in the county for more than two APH
crop years
A
I certify that I was not a member of another insured entity as a substantial beneficial
interest holder, which produced the insured crop in the county for more than two APH
crop years.
Substantive
I certify that any substantial beneficial interest holders for the policy in which new
producer status is requested, have not produced the insured crop in the county for more
than two APH crop years.”
“Comments:”
B
4 Required Statements
Substantive
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
5
A
Required Signatures
“Insured’s Printed Name, Signature and Date”
June 2015
FCIC 24040
Substantive
163
Exhibit 64
Request of Administrative Reinstatement
This form is to be completed by the ineligible person requesting reinstatement and submitted to the
Approved Insurance Provider.
1 Applicant Information
A “Name of Person Requesting Reinstatement”
“Ineligible Person’s Identification Number”
B
C “Ineligible Person’s Identification Number Type”
D “Ineligible Person’s Street and/or Mailing Address”
"City and State”
E
“Zip Code”
F
G “Ineligible Person’s Telephone Number”
H “State and County”
“Policy Number(s), if applicable”
I
“Insured’s Identification Number (if not the same as the ineligible person)”
J
K “Insured’s Identification Number Type (if not the same as the ineligible person)”
2 Request Information
A “Crop Year Reinstatement is Requested”
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
“Request Type (Check One)”
□ “Unavoidable or Unforeseen Event”
B
□
□
□
□
“Active Duty in U.S. Military”
“Failure to include All Amounts Due”
“Transposed Amount”
“7-day Transit Period”
C
“I hereby request reinstatement of my policy. I
understand that if my policy is reinstated I must
adhere to all applicable policy provisions and I
have paid any amounts due for the policy (ies) in
which I requested reinstatement.
D
“Statement of why reinstatement should be granted including explanation of the
circumstances which lead to your failure to pay your debt(s) timely. You must include
facts that are relevant to the request and which can be substantiated further by the
documentation provided with this request.”
E
I have attached the following documents:”
June 2015
FCIC 24040
Note: Allow space for the
Requestor to initial this statement.
Note: Allow space to include a
list of supporting documentation
164
Exhibit 64
Request of Administrative Reinstatement (Continued)
3
Required Statements
“If my policy is reinstated, I agree to present my
reinstatement letter to my insurance provider and
purchase the policy (ies) I have requested by the
due date that will be established in my
reinstatement letter.
A
I understand that failure to purchase the policies for
which I have requested will result in my
reinstatement being rescinded. In addition, I
understand that the coverage provided under the
reinstated policy will use the same plan of
insurance, coverage levels, endorsements and
options I had prior to termination, provided that I
continue to meet all eligibility requirements and
comply with the terms of the policy, and there is no
preliminary evidence of misrepresentation or
fraud.”
Note: Insert the following
statement above the Requestor’s
signature line. Allow space for
the Requestor to initial this
statement.
B
“I certify that [INSERT NAME OF REQUESTOR]
has met all other program requirements under the
authority of the Federal Crop Insurance Act (the
Act) with the exception of being listed as
ineligible. In addition, we certify that the
reinstated policy will maintain all the same
coverage levels and fund designation and comply
with the terms of the policy, and there is no
preliminary evidence of misrepresentation or fraud.
A
Certification Statement
Exhibit 2
Substantive
B
Privacy Act Statement
Exhibit 3
Substantive
C
Nondiscrimination Policy Statement
Exhibit 4
Substantive
4
Note: Insert the following
statement above AIP
representative‘s signature line.
Required Signatures
A
“Requestor’s Printed Name, Signature and Date”
Substantive
B
“AIP’s Authorized Representative’s Printed Name, Signature, and Date”
C
“AIP’s Authorized Representative’s Street and/or Mailing Address”
D
“AIP’s Authorized Representative’s Telephone Number”
Substantive
NonSubstantive
NonSubstantive
E
“Insured’s Printed Name, Signature, and Date
June 2015
FCIC 24040
Note: Provide instruction that
signature is to be obtained if the
Requestor is not the Insured.
Substantive
165
| File Type | application/pdf |
| File Title | Document and Supplemental Standards Handbook |
| Subject | Document and Supplemental Standards Handbook 2016 and Succeeding Crop Years |
| Author | Gilmore, April - RMA |
| File Modified | 2015-07-06 |
| File Created | 2015-07-01 |