2B.) Contact details:
5.)
6.)
A.) Annual Receipts from Crop Consulting
B.) Annual Gross Receipts from Sales of Agricultural Chemicals (refer Question 4B above)
7.) Please identify the services which you offer, and give the approximate percentage of fees
12.) Coverage Requested
I/WE HEREBY DECLARE THAT THE ABOVE STATEMENTS AND PARTICULARS ARE TRUE AND THAT I/WE HAVE NOT SUPPRESSED OR MIS-STATED ANY MATERIAL FACTS AND I/WE AGREE THAT THIS APPLICATION FORM SHALL BE THE BASIS OF THE CONTRACT WITH THE UNDERWRITERS, AND THAT I/WE UNDERSTAND THAT THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY.

LII 653 A-1 (08/18)

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