1 Application2 Signature3 Kansas4 Nebraska5 North Dakota6 Ohio7 Wisconsin INSTRUCTIONS: PLEASE ANSWER ALL QUESTIONS, LEAVING NO BLANK SPACES IF SPACE IS INSUFFICIENT TO ANSWER FULLY ANY QUESTIONS, ATTACH SEPARATE SHEET APPLICATION MUST BE SIGNED AND DATED BY OWNER, PARTNER OR OFFICER ENCIRCAsm CERTIFIED SERVICES AGENTS CROP CONSULTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION FORM (THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY) NOTE: In applying for the coverage, the applicant understands that in the event of an insured loss, the limit of liability and deductible shall be inclusive of the loss payment and the claim expenses as defined in the policy. 1.Name of Applicant:**IndividualPartnershipCorporationOther2.A) AddressStreet Address*City*State / Province*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonZIP / Postal Code*Web Site:*B) Contact details:Name:** Email address: Please repeat email address: Cell Phone:*3.A) Are you an Encirca Certified Services Agent?*YesNoB) If "Yes" when did you qualify as a Certified Services Agent ?*B) If "Yes" when did you qualify as a Certified Services Agent ?4.A). Are you currently engaged in any other occupation ?*YesNoIf Yes, state occupation and percentage of income derived from it:*If Yes, state occupation and percentage of income derived from it:B). Do you recommend any products for which you are a representative/distributor ?*YesNoIf Yes, please give details*If Yes, please give details5.A). Number of employees:Full Time:*Part Time:*B). Number of Independent Contractors*Please advise their names:*Please advise their names:6.A. Annual Receipts from Crop ConsultingLast 12 months $*Estimated Next 12 months $*B. Annual Gross Receipts from Sales of Agricultural Chemicals (refer Question 4.B above)Last 12 months $*Estimated Next 12 months $*Retained Margin:*7.Please identify the services which you offer, and give the approximate percentage of fees:*% Fertility Recommendations*% Contract Research*% Crop Inspection and Scouting*% Whole Farm Planning*% Pest Management Recommendations*% Equipment Selection/Management*% Integrated Crop Management*% Regulatory Compliance Recommendations*% Seed Variety Recommendations*% Crop Marketing*% Irrigation Scheduling*% Other, Please specify: *% Precision Farming Recommendations*100%8.Please list the types of crops on which you give advice:*9.Have any claims been made against you in the past five (5) years which resulted in payment or legal expenses ?*YesNoIf "Yes" please give details and the amounts paid:*If "Yes" please give details and the amounts paid:10.Are you aware, after enquiry, of any circumstances which may result in any claims being made against you, or any predecessors in business ?*YesNoIf "Yes" please give details:*If "Yes" please give details:11.Previous carrier for Professional Liability:*Privacy Period:Retroactive Date: Date Format: MM slash DD slash YYYY 12.Limits of Liability: $1,000,000Deductible requested:*$2,500$5,000$10,000 I/WE 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.DATE:*SIGNATURE OF APPLICANT:*CSA 8/18(A copy of your application will be automatically emailed to you once you click the submit button.) STATEMENT OF INSURED THIS FORM MUST BE COMPLETED IN DETAIL FOR EACH NEW RISK PLACED AND FOR RENEWAL OF PREVIOUSLY PLACED RISKS. A COPY OF THIS STATEMENT MUST BE PROVIDED TO THE INSURED AND MAINTAINED IN AGENT'S FILES. INSURED:*COVERAGE TYPE:POLICY PERIOD:TO:Check one of the options below:EXEMPT COMMERCIAL PURCHASER (defined in Sec. 527(5) of the Dodd-Frank Act) As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I understand, that as an exempt commercial purchaser, contrary to K.S.A. 40-246b, a diligent search of the admitted market is not required to place this coverage with a company that is non-admitted or licensed to transact business in this state. I further understand that such insurance may or may not be available from the admitted market that may provide greater protection with more regulatory oversight.ALL OTHER INSUREDS (Other than exempt commercial purchasers) As required by K.S.A. 40-246b, this will certify that I, the undersigned, have requested insurance coverage to be placed on my behalf with a company that is non-admitted or licensed to transact business in the State of Kansas. I understand that in accordance with K.S.A. 40-246b, t\iat mere rate differential shall not be grounds for placing a particular risk with a non-admitted company when an admitted company would accept such risk at a different rate.It is further acknowledged that the following information regarding placement of insurance with a non-admitted company, has been provided by the licensed excess lines agent: The insurance coverage requested will be provided by an insurance company that is non-admitted or licensed to transact business in the State of Kansas, and whose name appears on the list of non-admitted companies maintained by the Commissioner of Insurance. The non-admitted insurers' financial condition, policy forms, rates and trade practices are not subject to review or the jurisdiction of the Commissioner of lnsurance. There shall be no liability on the part of, and no cause of action of any nature shall arise against the Commissioner of Insurance, employees thereof, or the State of Kansas because the name of an insurance company appears or does not appear on the list of non-admitted companies maintained by the Commissioner of Insurance. The policies or contracts of insurance issued by a non-admitted insurance company do not come under the protection afforded by the Kansas Insurance Guaranty Association Act (K.S.A. 40-2901, et seq.). If the insurance company affording coverage is subsequently determined to be insolvent, the licensed excess lines agent placing such business with a company nonadmitted to transact business in Kansas is, by giving you the information contained herein, relieved of any responsibility to the insured as it relates to such solvency. Premium tax in the amount equal to 6% of the gross premiums shall be collected from insured and remitted to the Commissioner of Insurance by licensed agent. Where the insurance covers properties, risks or exposures located or to be performed both in and out of this state, the sum payable shall be computed based on: An amount equal to 6% of that portion of the gross premiums allocated to this state; plus an amount equal to the portion of the premiums allocated to other states or territories on the basis of the tax rates and fees applicable to properties, risks or exposures located or to be performed outside of this state; less the amount of gross premiums allocated to this state and returned to the insured. (K.S.A. 40-246c) Insured*Signature of Agent Date I was unavailable or otherwise unable to sign this statement prior to the effective date of coverage SOI (7/11)(A copy of your application will be automatically emailed to you once you click the submit button.)CAPTCHA STATE OF NEBRASKA SURPLUS LINES TAX CONSENT FORM AGENT:RE:POLICY NUMBER:DATE:"With regard to this application for insurance, said coverage or portions thereof, may be written in an Insurance Company that is not licensed to do business in Nebraska, and in the event of the insolvency of such company the policy will not be covered by the Nebraska property and liability insurance guaranty association."Signature of Agent DateSignature of Insured*DateSL-03/CB-O 1 1/79(A copy of your application will be automatically emailed to you once you click the submit button.) Notice: An insurer that is not licensed in this state is issuing the insurance policy that you have applied to purchase. These companies are called "non-admitted" or "surplus lines" insurers. The insurer is not subject to the financial solvency regulation and enforcement that applies to licensed insurers in this state. These insurers generally do not participate in insurance guaranty funds created by state law. These guaranty funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. Some states maintain lists of approved or eligible surplus lines insurers and surplus lines producers may use only insurers on the lists. Some states issue orders that particular surplus lines insurers cannot be used. For additional information about the above matters and about the insurer, you should ask questions of your insurance producer or surplus lines producer. You may also contact your insurance department consumer help line. (Name of Insured)*(Signature of Insured)*(Date)(A copy of your application will be automatically emailed to you once you click the submit button.) Product Regulation Property & Casualty 50 W. Town St. Suite 300 Columbus, OH 43215 (614) 644-2635 Fax (614) 728-1280 www.insurance.ohio.gov Ohio Department of Insurance John R. Kasich – Governor Mary Taylor – Lt. Governor/Director Surplus Lines Statement PART 1. STATEMENT OF SURPLUS LINE BROKER OR ORIGINATING AGENTacknowledges that he/she is a duly licensed full multiple line agent currently licensed with insurance companies, other than life, authorized to do business in Ohio or he/she is a duly licensed surplus line broker pursuant to section 3905.30 of the Ohio Revised Code and that after due diligence, he/she is unable to procure the insurance policy described below from insurers authorized to do business in Ohio to which he/she is a licensed agent.Property or risk to be insured:*He/she acknowledges that he/she has complied with the applicable requirements of due diligence as set forth in section 3905.33 of the Ohio Revised Code, and has explained to the insured the meaning of the signed statements prior to binding coverage and received declinations for the reasons set forth below from the following authorized insurer(s) to which he/she is so licensed and which are known to him/her to customarily write the kind of insurance described above.Insurers / ReasonsINSURERSREASONS Signature of Surplus Line Broker or Originating Agent PART 2. SIGNED STATEMENT OF INSURED AS REQUIRED BY SECTION 3905.33 OF THE OHIO REVISED CODEThe named insured*, acknowledges that the insurance policy (other than life insurance) as described above is to be placed with an insurance company not authorized to do business in Ohio. The insured understands that the insurance company is not a member of the Ohio Insurance Guaranty Association and that Chapter 3955 of the Ohio Revised Code is not applicable to claimants or insureds of said insurance company. The surplus line broker shall collect the Ohio tax of five percent of the amount of the premium for the insurance policy at the time the insurance policy is delivered to the insured.Signature of Insured:* INS4024 (Rev. 07/2015) Accredited by the National Association of Insurance Commissioners (NAIC) Page 1 of 1 (A copy of your application will be automatically emailed to you once you click the submit button.) APPENDIX I Ins. 6.19 Notice of Directly Placed Unauthorized Insurance To: Commissioner of Insurance State of Wisconsin 123 West Washington Avenue Madison, WI 53702 From: Risk Placement Services, Inc. Two Pierce Place Itasca, IL 60143 Name of Person or Organization Insured:*Address of Insured:*Contract Number:Effective Date:Expiration Date:Name & Address of Insurance Company:Description or Type of Coverage:Premium Charged:The undersigned certifies that this report is true and correct according to the best of his information, knowledge, and belief.Signature*Date*Note: This report pursuant to s. 618.42(2), Stats., must be filed with the Commissioner of Insurance within 60 days after effectuation of any new or renewal insurance contract independently procured from an unauthorized insurer. A separate report is required for each new or renewal insurance contract. A 3% Tax on the premiums charged for such contracts during the calendar year ending December 31 must be paid to the Commissioner on or before March 1 next succeeding(A copy of your application will be automatically emailed to you once you click the submit button.) This iframe contains the logic required to handle Ajax powered Gravity Forms.