Application/Change/Transfer/SSN/EIN Form

Dairy Revenue Protection

Applicant’s/Insured’s Name and Address Agent’s Name and Address Policy Number/State Effective Crop Year/Season

FB Membership No. Account Number

Power of Attorney

Phone: Alt. Phone: Phone: Agent Code: Assignment of Indemnity

Email: Email:
Identification Type Identification Number *Spouse’s Name Spouse’s SSN Additional Applicant/Insured Information
SSN EIN RAN Yes No Is applicant at least 18 years old?
Person Type
*Married Individual (Spousal) Trust - Irrevocable Trust - BIA
Individual (Not Married) Trust - Revocable Receiver or Liquidator
Indiv. Operating as Business Estate Non-Profit or Tax-Exempt Org.
Partnership Joint Venture State/Local Government
Corporation: Limited Liability Company: Public Schools
State Incorporation Filed: ______ State Incorporation Filed: ______

Authorized Representative(s)
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.
Any change in entity or plan of insurance, adding or removing crops/counties, or cancellations require recertification of the Authorized Representative. (The Named Insured is required to sign.) Additional documents may be required.

MAKE NO CHANGES TO MY EXISTING COVERAGE CANCEL INSURANCE (See Required Statements) TRANSFER (See Required Statements)
Action:
ADD Plan of
CHG County Name * Name of Crop
Insurance
DLT

* Name of the County where your dairy operation is physically located. If it spans multiple counties, then the application county is the one in which the largest value of milk is
produced.

Page ___ of ___

Signatures required on final page.

 Application/Change/Transfer/SSN/EIN Form
Dairy Revenue Protection
Required Statements
Applicant’s/Insured’s Name Agent’s Name Policy Number/State Effective Crop Year/Season

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. 1501-1524) 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 RMA-approved 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.
NON-DISCRIMINATION STATEMENT
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating on the basis of race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, martial status, family/parental status, income derived from a
public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or actvitiy conducted or funded by USDA (not all bases apply to all programs). 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 https://www.ascr.usda.gov/ad-3027-usda-program-discrimination-complaint-form, 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,
Office of Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or email at program.intake@usda.gov. Persons with Disabilities: Persons with disabilities who require alternative
means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible State or local Agency that administers the program or USDA’s TARGET Center at
(202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additional, program information may be made available in languages other than English. Persons with disablities, who wish to
file a program complaint, please see information above on how to contact the Department by mail directly or by email.
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).

Signatures required on final page. Page ___ of ___

 Application/Change/Transfer/SSN/EIN Form
Dairy Revenue Protection
Required Statements
Applicant’s/Insured’s Name Agent’s Name Policy Number/State Effective Crop Year/Season

APPLICATION CONDITIONS OF ACCEPTANCE CANCEL INSURANCE

This application is accepted and insurance attaches in accordance with the policy unless: (1) The Federal Crop Insurance I hereby request cancellation of my crop insurance policy for the crop(s) and crop year
Corporation determines that, in accordance with the regulations, the risk is excessive; (2) any material fact is omitted, shown on this cancellation. I understand that if this form is not executed on or before
concealed or misrepresented in this application or in the submission of this application; (3) you have failed to provide the cancellation date for any crop year listed, the cancellation of insurance on such
complete and accurate information required by this application; or (4) the answer to any of the following questions is "yes." crop(s) will not become effective until the following crop year.
An answer of "yes" to these questions does not automatically result in rejection of the application. For example, if you answer REASON FOR CANCELLATION
"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, POLICY TRANSFER REQUEST PROVIDE INSURANCE
producing, harvesting, or storing a controlled substance? Ceding AIP Box I hereby request cancellation of my By submission of this form, we
insurance policy with the Ceding AIP shown below agree to provide crop
(c) Have you ever had insurance coverage under the authority of the Federal Crop Insurance Act terminated for for the crop(s) and crop year(s) shown because I insurance to this applicant for
violation of the terms of the contract or regulations, or for failure to pay your delinquent debt? the crop(s) and crop year
have applied for insurance with another Approved
specified unless this form is not
(d) Are you disqualified or debarred under the Federal Crop Insurance Act, the regulations of the Federal Crop Insurance Provider. I understand that if this form is executed on or before the
Insurance Corporation, or the United States Department of Agriculture? not executed on or before the established established cancellation date
cancellation date for any crop listed, the cancellation for any of the crop(s) shown, in
(e) Have you ever entered into an agreement with the Federal Crop Insurance Corporation or with the Department of insurance on such crop(s) will not become which case insurance will be
of Justice that you would refrain from participating in programs under the authority of the Federal Crop effective until the following crop year. provided for such crop(s) for
Insurance Act and that agreement is still effective? the following crop year.
I hereby authorize and direct the Ceding AIP shown
below to furnish any information relative to my Assuming Agent’s Name and
(f) Do you have like insurance on any of the above crop(s)? Address
insurance policy to the Assuming AIP listed below. I
I understand that if coverage for any crop is currently terminated or would have subsequently terminated for indebtedness understand that if coverage for any crop(s) is now
had this application been filed after the termination date, no coverage can be provided and I am ineligible for any benefits terminated or would have subsequently terminated
under the Federal Crop Insurance Act until the cause for termination is corrected. for delinquent debt had this transfer not occurred, no Assuming AIP Representative
We will notify you of rejection by depositing notification in the United States mail, postage paid, to the applicant’s address. coverage can be provided by the Assuming AIP.
Unless rejected or the sales closing date has passed at the time you signed this application, insurance shall be in effect for the X
crop(s) and crop years specified and shall continue for each succeeding crop year, unless otherwise specified in the policy, until Ceding Approved Insurance Provider (AIP) Assuming AIP Acceptance Date
canceled, terminated or voided. The insurance contract, which includes the accepted application, is defined in the regulation
published at 7 CFR chapter IV, this is not applicable to Rainfall and Vegetation Index plans. 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. Assuming Approved Insurance Provider (AIP) Assuming AIP Code & PIC Code
PAYMENT TERMS
The Applicant/Insured agrees to pay the Company the Crop Insurance premium shown as "Amount Due" on the Summary of
Coverage of the Policy, issued as a result of this Application. Interest will accrue at the rate of 1.25 percent simple interest CHANGE INSURANCE
per calendar month, or any portion thereof, on any unpaid amount due us. For the purpose of premium amounts due us, the
interest will start to accrue on the first day of the month following the premium billing date specified in the Special Provisions. Change/Correct insured’s address Add or remove SBI
Expenses of collection and reasonable attorney fees are payable by the Applicant/Insured. *Correct insured’s identification number *Correct SBI’s identification number
Correct spelling of insured’s name Correct spelling of SBI’s name
REMARKS
Add/change/correct insured’s authorized representative

REMARKS
* Enter previous identification number if this item is checked.

Applicant’s/Insured’s Printed Name and Signature Date Agent’s Printed Name and Signature Agent Code Date
Note: if you are not the named insured, add your title and authority to sign for the insured.

Print Print
Page ___ of ___
X X
See additional page for required statements.
 Social Security Number (SSN) and
Employer Identification Number (EIN)
Reporting/Verification Form
Policy Number/State Crop Year

Page ___ of ___

* PLEASE REVIEW AND VERIFY *
Below is the information that we have received on your policy. Please check thoroughly for accuracy. Failure to provide
accurate Social Security Numbers (SSN), Employer Identification Numbers (EIN) and/or RMA Assigned Number (RAN) may
result in voidance of your policy in accordance with the Basic Provisions. If any changes, additions, or deletions are made,
please sign, date and return the form.
Applicant’s/Insured’s Name and Address Agent’s Name and Address

Phone: Phone: Agent Code:

Identification Type Identification Number Email:
SSN EIN RAN
Person Type

List all persons with a substantial beneficial interest(SBI) in the applicant/insured as defined in the applicable policy provisions. (Include landlords or tenants
insured under the applicant). Landlord/Tenant SBI must be listed below regardless of interest in the applicant, IF INSURED ON THIS POLICY. If none, state
NONE.
Telephone Identification Number Action:
Landlord Add,Chg,
Other Person(s) Name and Address Number *Person Type Tenant
Identification Type Del

Enter corrected if changing:

SSN EIN RAN

Enter corrected if changing:

SSN EIN RAN

Enter corrected if changing:

SSN EIN RAN

Enter corrected if changing:

SSN EIN RAN

* Person Types
Married Individual (Spousal) Transfer Right of Indemnity Estate Public Schools
Individual Trust - Irrevocable Trust - BIA
Individual Operating as Business Trust - Revocable Receiver or Liquidator
Corporation Limited Liability Company Non-Profit or Tax-Exempt Org.
Partnership Joint Venture State/Local Government
Remarks

See reverse side or additional page for required statements.