QLA Program

Instructions For FSA-895
Crop Insurance and/or NAP Coverage Agreement
This information will be used to determine eligibility for WHIP+ and/or QLA
Progrma benefits on an insurable crop and/or on a noninsurable crop. Producers
are required to purchase insurance, or NAP Coverage, as applicable, on that
crop(s), trees, bushes, or vines for the next two consecutive crop years following the
crop year for which the benefits are requested, according to the producer’s
certification on this form.
Submit the original of the completed form in hard copy or facsimile to the
appropriate USDA servicing office.
Customers who have established electronic access credentials with USDA may
electronically transmit this form to the USDA servicing office, provided that (1) the
customer submitting the form is the only person required to sign the transaction, or
(2) the customer has an approved Power of Attorney (Form FSA-211) on file with
USDA to sign for other customers for the program and type of transaction
represented by this form.
Features for transmitting the form electronically are available to those customers
with access credentials only. If you would like to establish online access credentials
with USDA, follow the instructions provided at the USDA eForms web site.

Producers must complete Items 1 through 2, and 1A through 2B.
Fld Name /
Item No.

Instruction

1
Certification
Statement

Check only if applying for WHIP+ and/or QLA Program benefits on
at least one insurable crop. The producer certifies to purchase crop
insurance at a level of 60/100 or the equivalent for the crop(s), trees,
bushes or vines for the next two consecutive years following the crop
year which the benefits are requested, and if the certification
statement in Item 1 applies.

2
Certification
Statement

Check only if applying for WHIP+ and/or QLA Program benefits on
at least one insurable crop. The producer certifies to purchase NAP
Coverage at a level of 60/100 the crop(s), trees, bushes or vines for
the next two consecutive years following the crop year which the
benefits are requested and if the certification statement in Item 2
applies.
Enter the producer’s name.

3A
Producer’s
Page 1 of 2

As of: (09-11-19)

Fld Name /
Item No.
Name
3B
Signature

Instruction

If you are mailing or faxing this form, print the form and manually
enter your signature. If this form is approved for electronic
transmission and you have established credentials with USDA to
submit forms electronically, use the buttons provided on the form for
transmitting the form to the USDA servicing office.

3C
Date

Enter the date producer signs the agreement.

4A
County FSA
Office Name
and Address
4B
Telephone No.

Enter County FSA Office name and address.

Page 2 of 2

Enter County FSA Office telephone number including area code.

As of: (09-11-19)