Documents and Supplement Standards Handbook

United States
Department of
Agriculture

Federal Crop
Insurance Corporation
FCIC-24040 (06-2023)

DOCUMENT AND
SUPPLEMENTAL
STANDARDS
HANDBOOK
2024 and Succeeding Crop Years

THIS PAGE IS INTENTIONALLY LEFT BLANK

UNITED STATES DEPARTMENT OF AGRICULTURE
FARM PRODUCTION AND CONSERVATION
RISK MANAGEMENT AGENCY
TITLE: 2024 DOCUMENT AND SUPPLEMENTAL
STANDARDS HANDBOOK
EFFECTIVE DATE: 2024 and Succeeding Crop Years
SUBJECT:
2024 Document and Supplemental Standards
Handbook

NUMBER: FCIC-24040
OPI: Product Administration and Standards
Division
ISSUE DATE: June 29, 2023
APPROVED:
/s/ John W. Underwood for
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 2024 and succeeding crop years.
This directive is effective on the date issued and will remain in effect until superseded or reissued. RMA will
amend this directive to administer programs reinsured by FCIC under authority of the Federal Crop Insurance
Act, 7 U.S.C. 1501 et. seq. FCIC-24040 Document and Supplemental Standards Handbook dated June 29, 2023,
is effective for all crops with a contract change date of June 30, 2023, or later.
SUMMARY OF CHANGES
Listed below are the changes to the 2024 FCIC-24040 Document and Supplemental Standards Handbook with
significant content change. All changes and additions are highlighted. Minor changes and corrections are not
included in this listing. *** used throughout the handbook indicate where major deletions occurred. All
forms with changes must be modified by December 31, 2023, and are effective for policies with a contract
change date after the directive’s publication.
REFERENCE
TP page(s)
Para. 1B
Para. 1D
Paras. 603 &
605
Exh. 3-87
Exh. 16 & 18

June 2023

DESCRIPTION OF CHANGE
Removed control chart and combined the filing instructions with the reason for issuance.
Corrected the PRWORA source of authority reference.
Updated the related handbook purpose statements for the CIH, GSH, ITS and WFRP
handbooks.
Changed submission instruction of NDS “AIP Annual Certification to RMA” and “Controlled
Business Notification to RMA” from a physical address to e-mailing the AIP assigned
Reinsurance Services Division Account Executive.
Adjusted formatting of all Form Standards to provide more readability.
Changed the element in the Required Signatures section from “Applicant/Insured’s Printed
Name, Signature and Date” to “Applicant’s Printed Name, Signature and Date” in the
Application and the STAX Application form standards to be consistent with the elements in
the Applicant’s Information section of these form standards.
FCIC-24040

TP 1

RISK MANAGEMENT AGENCY DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
SUMMARY OF CHANGES (Continued)
REFERENCE
Exh. 17

Exh. 19
Exh. 21 & 22
Exh. 22

Exh. 23
Exh. 24
Exh. 24, 56 &
64
Exh. 31

Exh. 57
Exh. 57, 59, &
68

Exh. 58

Exh. 59
Exh. 62

June 2023

DESCRIPTION OF CHANGE
Changed to the title of the Insured Information section, making it Applicant/Insured
Information. Changed elements in the Applicant/Insured Information section from
“Insured’s Name” to “Applicant/Insured’s Name” and in the Required Signature section
from “Insured’s Printed Name, Signature and Date” to “Applicant/Insured’s Printed Name,
Signature and Date” since the SCO Endorsement form standard is an application.
Added space to the list of services for VFR portion of Application.
Added the designation of Non-Substantive to Added County Election and Designated
County to the Policy Transfer/Application and Policy Change standards to be consistent
with the Application standards.
Changed the title of the Applicant Information section, making it Insured Information.
Changed an element in the Required Signature section from “Applicant/Insured’s Printed
Name, Signature and Date” to “Insured’s Printed Name, Signature and Date” since the
Policy Change form is not an application.
Changed an element in the required signature section to make it “Applicant/Insured’s
Printed Name, Signature and Date” to be consistent with the elements in the
Applicant/Insured’s information section in this form standard.
Changed required statement for organic producers to refer to an organic system plan
rather than an organic plan.
Changed all instances of Approved APH Yield(s) to Approved Yield(s).
Added Plan of Insurance or Percentage of Price to Crop Information and expanded the
Terms and Conditions that correspond with HRLEO changes by adding elements for
electing an additional coverage policy for high-risk acreage excluded from the base policy
(formerly HRACE).
Changed several items in Crop Information to non-substantive for cranberries and lowbush
blueberries and added a note to Percent Stand.
Changed an element in the required signature section in the Producer’s Pre-Acceptance
Worksheet, Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet, and Florida Fruit
Tree Producer’s Pre-Acceptance Worksheet to make it “Applicant’s/Insured’s Printed
Name, Signature and Date” to be consistent with the elements in the general information
section in these form standards.
Changed items in the section for the inspector to complete: added Non-substantive
designation to “Describe Wildlife control measures”, adjusted table rows for specific
management practices (deleted Pruning Program and added Fungicide Program); and
removed two questions. Added to the acreage/inspection table for Percent Stand for
cranberries and lowbush blueberries.
Deleted Number of Plants from the Note for the Totals in the Crop Information section.
Added the designation of Non-Substantive to Forage Stems per Sq. Ft. and Forage Plants
per Sq. Ft.

FCIC-24040

TP 2

RISK MANAGEMENT AGENCY DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
SUMMARY OF CHANGES (Continued)
REFERENCE
Exh. 67

***

June 2023

DESCRIPTION OF CHANGE
Changed two elements in the general information section making them;
“Applicant/Insured’s Name” and “Applicant/Insured’s Authorized Representative” and one
element in the required signatures section to make it “Applicant/Insured’s Printed Name,
Signature and Date” since the Sprinkler Irrigated Rice Endorsement form standard is an
application.

FCIC-24040

TP 3

DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
TABLE OF CONTENTS
PART 1: GENERAL INFORMATION AND RESPONSIBILITIES ..............................................................................1
1
2
3
4
5-200

General Information ......................................................................................................................1
Responsibilities..............................................................................................................................3
The Privacy Act of 1974 .................................................................................................................4
Freedom to E-File ..........................................................................................................................4
(Reserved) .....................................................................................................................................5

PART 2: NON-REINSURED SUPPLEMENTAL CROP INSURANCE POLICIES .........................................................6
201 General Information ......................................................................................................................6
202 Submission Requirements .............................................................................................................6
203 Review of NRS Crop Insurance Policies .........................................................................................6
204-300 (Reserved) ................................................................................................................................6
PART 3: FORM STANDARDS OPERATING POLICY ............................................................................................7
301 Form Development .......................................................................................................................7
302 Substantive versus Non-Substantive .............................................................................................7
303 Combined Form Standards ............................................................................................................7
304 Signatures......................................................................................................................................7
305 Interest Rates ................................................................................................................................8
306 Required Statements.....................................................................................................................8
307-400 (Reserved) ................................................................................................................................8
PART 4: GENERAL FORM STANDARDS ............................................................................................................9
401 Form Style .....................................................................................................................................9
402 Identification Numbers .................................................................................................................9
403 Person Types ...............................................................................................................................10
404 Substantial Beneficial Interest Holder .........................................................................................10
405 Agent/Loss Adjuster Code ...........................................................................................................11
406 State and County Name ..............................................................................................................11
407 AIP Name and Address ................................................................................................................11
408 Street and/or Mailing Address ....................................................................................................11
409 City, State, Zip Code ....................................................................................................................11
410 Added County Election ................................................................................................................11
411 Landlord/Tenant Insuring Other’s Share .....................................................................................12
412 Price Election ...............................................................................................................................12
413 Options, Elections, or Endorsements ..........................................................................................12
414 Actuarial Fields ............................................................................................................................13
415-500 (Reserved) ..............................................................................................................................13

June 2023

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DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
TABLE OF CONTENTS
PART 5: GENERAL REQUIRED STATEMENTS AND DISCLOSURES .................................................................... 14
501 RMA Privacy Act Statement - Collection of Information and Data ..............................................14
502 RMA Certification Statement ......................................................................................................14
503 RMA Non-Discrimination Statement ...........................................................................................15
504 USDA Multiple Benefit Statement ...............................................................................................17
505 Native Sod ...................................................................................................................................17
506 Conservation Compliance - Exception .........................................................................................17
507 Conditions of Acceptance Statement ..........................................................................................18
508-600 (Reserved) ..............................................................................................................................18
PART 6: AIP REQUIRED STATEMENTS AND DISCLOSURES ............................................................................. 19
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 ....................................................................................26
606 Race, Ethnicity and Gender (REG) Disclosure Statement.............................................................29
607-700 (Reserved) ..............................................................................................................................29
FORM STANDARD EXHIBITS .......................................................................................................................... 30
Exhibit 1 (Reserved) ..............................................................................................................................30
Exhibit 2 (Reserved) ..............................................................................................................................31
Section 1: General Statements and Disclosures ................................................................................ 32
Exhibit 3 Conservation Compliance - Exception ....................................................................................32
Exhibit 4 Conditions of Acceptance Statements ...................................................................................37
Exhibit 5 Request for Administrative Reinstatement ............................................................................38
Section 2: AIP Statements and Disclosures ....................................................................................... 41
Exhibit 6 Anti-Rebating Certification.....................................................................................................41
Exhibit 7 AIP Non-Disclosure Statement ...............................................................................................43
Exhibit 8 Individual Non-Disclosure Statement .....................................................................................45
Exhibit 9 Conflict of Interest .................................................................................................................47
Exhibit 10 Individual Controlled Business Certification ...........................................................................50
Exhibit 11 Affiliate Controlled Business Certification ..............................................................................52
Exhibit 12 REG Disclosure Statement......................................................................................................54
Exhibit 13-15 (Reserved) ......................................................................................................................56

June 2023

FCIC-24040

TC 2

DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
TABLE OF CONTENTS
FORM STANDARD EXHIBITS (Continued)
Section 3: Policy Forms ..................................................................................................................... 57
Exhibit 16 Application .............................................................................................................................57
Exhibit 17 Supplemental Coverage Option Endorsement Application ....................................................60
Exhibit 18 STAX Application ....................................................................................................................62
Exhibit 19 BFR and VFR Application ........................................................................................................65
Exhibit 20 Policy Cancellation .................................................................................................................71
Exhibit 21 Policy Transfer/Application ....................................................................................................73
Exhibit 22 Policy Change .........................................................................................................................76
Exhibit 23 Social Security Number and Employer Identification Number Reporting ..............................80
Exhibit 24 Acreage Report ......................................................................................................................82
Exhibit 25 Summary of Coverage (Schedule of Insurance)......................................................................87
Exhibit 26 Policy Confirmation (Policy Declaration) ................................................................................90
Exhibit 27 Power of Attorney..................................................................................................................92
Exhibit 28 Assignment of Indemnity .......................................................................................................95
Exhibit 29 Continuous Hail and Fire Exclusion Option ............................................................................97
Exhibit 30 Annual Request for Hail and Fire Exclusion Option .............................................................. 101
Exhibit 31 High-Risk Land Exclusion Option .......................................................................................... 104
Exhibit 32 Transfer of Coverage and Right to an Indemnity.................................................................. 108
Exhibit 33 Withdrawal of Claim for Indemnity ...................................................................................... 111
Exhibit 34 Request for an RMA Assigned Identification Number .......................................................... 112
Exhibit 35 Request to Waive Administration Fee for Limited Resource Farmer ................................... 114
Exhibit 36 Unit Division Option ............................................................................................................. 116
Exhibit 37 New Producer Certification .................................................................................................. 118
Exhibit 38 Unit Division by Grid Option (UDGO) ................................................................................... 120
Exhibit 39-50 (Reserved) .................................................................................................................... 123
Section 4: Category B, C and D Forms ............................................................................................. 124
Exhibit 51 RMA Regional Office Determined Yield Request .................................................................. 124
Exhibit 52 Production Report................................................................................................................ 128
Exhibit 53 Actual Production History Database .................................................................................... 131
Exhibit 54 Summary of Revenue History Database ............................................................................... 133
Exhibit 55 Revenue Report ................................................................................................................... 135
Exhibit 56 Agreement to Combine Optional Units ................................................................................ 137
Exhibit 57 Producer’s Pre-Acceptance Worksheet................................................................................ 140
Exhibit 58 Perennial Crop Pre-Acceptance Inspection Report .............................................................. 143
Exhibit 59 Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet ................................................. 148
Exhibit 60 Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report ................................ 150
Exhibit 61 Weighted Average Age/Density Worksheet ......................................................................... 155
Exhibit 62 Forage Production Underwriting Report .............................................................................. 156
Exhibit 63 Hybrid Seed Yield Request ................................................................................................... 158

June 2023

FCIC-24040

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DOCUMENT AND SUPPLEMENTAL STANDARDS HANDBOOK
TABLE OF CONTENTS
FORM STANDARD EXHIBITS (Continued)
Section 4: Category B, C and D Forms (Continued)
Exhibit 64 Irrigated Practice Guidelines ................................................................................................ 159
Exhibit 65 Grass Seed Underwriting Report .......................................................................................... 164
Exhibit 66 Forage Seed Underwriting Report........................................................................................ 166
Exhibit 67 Sprinkler Irrigated Rice (SIR) Endorsement Application ....................................................... 167
Exhibit 68 Florida Fruit Tree Producer’s Pre-Acceptance Worksheet ................................................... 173
Exhibit 69 Marketing Certification ........................................................................................................ 176
Exhibits 70-80 (Reserved) ................................................................................................................... 186
Section 5: Loss Adjustment Forms .................................................................................................. 187
Exhibit 81 Certification Form ................................................................................................................ 187
Exhibit 82 Self-Certification Replant Worksheet ................................................................................... 191
Exhibit 83 Claim Checklist ..................................................................................................................... 196
Exhibit 84 Loss Adjustment Simplified Claims Qualification Process and Notice of Loss ...................... 198
Exhibit 85 Loss Adjustment Notice of Damage or Loss ......................................................................... 202
Exhibit 86 Loss Adjustment Notice of Prevented Planting .................................................................... 205
Exhibit 87 Growing Season Inspection Report ...................................................................................... 207

June 2023

FCIC-24040

TC 4

PART 1: GENERAL INFORMATION AND RESPONSIBILITIES
1

General Information
A.

Purpose
The FCIC is a wholly owned government corporation established by the ACT, 7 U.S.C. 1501. 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 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 NRS in accordance with the SRA for the 2024 and succeeding CYs.

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:

June 2023

(1)

the ACT, 7 U.S.C. 1501 et seq.;

(2)

The Food Security Act of 1985, 16 U.S.C. 3801 et seq;

(3)

Controlled Substance Act of 1970, 21 U.S.C. 801 et seq;

(4)

PRWORA, 8 U.S.C. 1601 et seq.;

(5)

Privacy Act of 1974, 7 U.S.C. 552a;

(6)

Freedom to E-File Act, P.L. 106-222;

(7)

Agriculture General Administrative Regulation, 7 CFR part 400;

(8)

HELC and WC, 7 CFR part 12; and

(9)

SRA and LPRA.

FCIC-24040

1

1

General Information (Continued)
C.

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 they 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 USDA public website at
www.ascr.usda.gov. See Para. 503 for information about the RMA Non-Discrimination
Statement.

D.

Related Handbooks
The following table provides directives closely related to this handbook. However, other RMA
approved handbooks may reference this handbook when applicable.
Handbook
CIH

GSH

ITS

LAM
NISH
RI
STAX

June 2023

Relation/Purpose
This handbook provides the official FCIC-approved underwriting standards for
policies administered by AIPs for the General Administrative Regulations;
Common Crop Insurance Policy Basic Provisions and Area Risk Protection
Regulations.
This handbook provides the official FCIC-approved standards for policies
administered by AIPs under the General Administrative Regulations; Common
Crop Insurance Policy Regulations Basic Provisions, including the Catastrophic
Risk Protection Endorsement; the Area Risk Protection Insurance Regulations
Basic Provisions; the Stacked Income Protection Plan of Insurance; the Rainfall
Index Plan; and the Whole-Farm Revenue Protection Pilot Policy.
This handbook provides the official FCIC-approved standards for use in
reporting, administering, and maintaining the Ineligible Tracking System,
identifying and notifying ineligible persons and implementing RMA and AIP
reinstatement.
This handbook provides the official FCIC-approved general loss adjustment
standards for all levels of insurance provided under FCIC unless a publication
specifies that none or only specified parts of this handbook apply.
Provides instructions for administration of the nursery crop provisions.
This handbook provides the official FCIC-approved underwriting,
administration and review standards for the Rainfall Index plan of insurance.
This handbook provides the FCIC-approved procedures for administering STAX.

FCIC-24040

2

1

General Information (Continued)
D.

Related Handbooks (Continued)
Handbook
WAH
WFRP

E.

Relation/Purpose
This handbook provides the standards and criteria for WAs and instructions for
each RMA RO and AIP to process WA requests.
This handbook provides information, procedures and instructions for
administering the WFRP program, including Micro Farm.

Procedural Issuance Authority
This handbook is written and maintained by:
USDA-Risk Management Agency
Office of Deputy Administrator for Product Management
Product Administration and Standards Division
For applicable RMA Regional or Compliance office contacts referenced throughout this
handbook, refer to www.rma.usda.gov/en/RMALocal/Field-Offices/Regional-Offices or
www.rma.usda.gov/en/RMALocal/Field-Offices/Regional-Compliance-Offices.

F.

Procedural Questions
Questions regarding form standards and procedures may be directed to RMA PASD,
Underwriting Standards Branch via the PIL or the e-mail addresses as provided in GSH Para. 1G.

G.

Acronyms and Abbreviations
See the GSH for applicable acronyms and definitions.

2

Responsibilities
A.

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.

B.

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.

June 2023

FCIC-24040

3

3

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, RMA is authorized by the 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.

4

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)

(2)

B.

Sec 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 (see GSH Para. 814 for electronic communication requirements for
policy provision changes);

(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 with the
Freedom to E-File Act; Sec 3(b).

AIPs 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)

AIPs must meet these requirements prior to approval for an SRA.

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 2023

FCIC-24040

4

5-200 (Reserved)

June 2023

FCIC-24040

5

PART 2: NON-REINSURED SUPPLEMENTAL CROP INSURANCE POLICIES
201

General Information
An NRS policy is a policy, endorsement, or other risk management tool not reinsured by FCIC under the
ACT, that offers additional coverage, other than for loss related to hail. Loss related to hail includes
wind and fire coverage for damage associated with a hailstorm.

202

Submission Requirements
Any NRS policy that covers the same agricultural commodity as any policy reinsured by FCIC under the
ACT must be provided to RMA. If changes are made to a previously reviewed NRS or five years have
lapsed since RMA’s review, the NRS must be submitted for review. Failure to provide such NRS policy
or endorsement to RMA prior to its issuance shall result in the denial of reinsurance, A&O subsidy, and
risk subsidy on all underlying FCIC reinsured policies unless the underlying FCIC policy was sold by
another AIP. If the underlying FCIC reinsured policy is sold by another AIP, the AIP that sold the NRS
may be required to pay FCIC an amount equal to the reinsurance, A&O subsidy, and risk subsidy on the
underlying FCIC policy.
An electronic copy in Microsoft Office compatible format of the new or revised NRS policy and related
materials must be submitted at least 150 days prior to the first SCD applicable to the NRS policy. At a
minimum, examples that demonstrate how liability and indemnities are calculated under differing
scenarios must be included. Electronic copies of the NRS must be sent to the Deputy Administrator for
Product Management at [email protected].

203

Review of NRS Crop Insurance Policies
The AIP shall not sell an NRS policy unless it has complied with the requirements of 7 CFR § 400.713.
RMA shall review the NRS policy to determine whether it materially increases or shifts risk to the
underlying policy or plan of insurance, reduces or limits the rights of insured, causes market disruption,
provides an impermissible rebate, or is conditioned upon or provides incentive for the purchase of the
underlying policy or plan of insurance reinsured by FCIC with a specific agent or approved insurance
provider.
(1)

RMA will have 75 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.

204-300

June 2023

(Reserved)

FCIC-24040

6

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 LASHs,
WAH, 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 versus 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 AIP’s established EBIP and the Electronic Signatures in Global and National
Commerce Act (15 USC §7001 - §7006). Rubber or similar signature or date stamps are not acceptable.
See 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.

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7

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 sec 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, and the time and date to the
form where such statement(s) have been refused.

307-400

June 2023

(Reserved)

FCIC-24040

8

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 SSN, EIN, or RAN.
A.

Form Completion Instructions
Form completion instructions must:

June 2023

(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.

FCIC-24040

9

402

Identification Numbers (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. The identification number must not be masked when
reported by the person providing the identification number.
AIP must provide unmasked data when a Policy Transfer/Application from one AIP to another
AIP to verify correct policy information.
If the identification number is unmasked in order to provide the applicant/insured an
opportunity to verify whether the identification number, or to assist in a transfer, 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
□ RAN
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 during loss adjustment. 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 are required on each individual
form unless it is collected on the Social Security Number and Employee Identification Number
Reporting form (see Exhibit 23).

June 2023

FCIC-24040

10

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
06/01/2018
12RMA34
(Agent’s Signature)
(Date)
(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:
408

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.

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,” and “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.

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

June 2023

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.

FCIC-24040

11

410

Added County Election (Continued)
□ 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 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 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 noninsuring 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)

“Is applicant insuring the tenant’s share?” “Yes □ No □”
“Is applicant insuring the landlord’s share?” “Yes □ No □”; or

(2)

(3)
412

“In addition to my share on this policy, I am insuring:
□

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.

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.

June 2023

FCIC-24040

12

413

Options, Elections, or Endorsements (Continued)
Otherwise, AIPs must use the following forms for an insured to elect, add, exclude, or otherwise
modify coverage.

414

(1)

Required on or before the SCD, AIPs must use the Application or the Policy Change form.

(2)

Required on or before the ARD or PRD, AIPs must use the Policy Change form.

Actuarial Fields
The actuarial documents and RMA processing systems include the following subfields under Type and
Practice.
(1)

(2)

Type (Substantive)
(a)

Commodity Type (Non-Substantive)

(b)

Class (Non-Substantive)

(c)

Subclass (Non-Substantive)

(d)

Intended Use (Non-Substantive)

Practice (Substantive)
(a)

Irrigation Practice (Non-Substantive)

(b)

Cropping Practice (Non-Substantive)

(c)

Organic Practice (Non-Substantive)

(d)

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

415-500

June 2023

Type:
Type:
Class Subclass

Type:
Intended
Use

Practice:
Irrigation
Practice

Practice:
Cropping
Practice

Practice:
Organic
Practice

Practice:
Interval

(Reserved)

FCIC-24040

13

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.
Required Statement:
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 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.

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.

June 2023

FCIC-24040

14

502

RMA Certification Statement (Continued)
If a form standard contains 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.
Required 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).

503

RMA Non-Discrimination Statement
It is the AIP’s 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. The RMA and USDA Non-Discrimination Statement is available on the RMA public website
at:
(1)

RMA Non-Discrimination Statement: www.rma.usda.gov/About-RMA/Laws-andRegulations/Required-Statements/Non-Discrimination-Statement

(2)

Office of Assistant Secretary for Civil Rights: www.usda.gov/oascr

A.

General
The non-discrimination statement shall be posted in Approved Insurance Provider (AIP) and
agent offices, on websites, forms and in newsletters and advertisements. Additionally, all
materials released to the public for distribution, including fact sheets, brochures, and any
Federal crop insurance related materials must include the non-discrimination statement.

B.

Forms
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, marital 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 activity conducted or funded by USDA (not all bases apply to all programs).

June 2023

FCIC-24040

15

503

RMA Non-Discrimination Statement (Continued)
B.

Forms (Continued)
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 www.usda.gov/oascr, 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, Center for Civil Rights Enforcement, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410 or email at
[email protected].
Persons with Disabilities
Persons with disabilities who require alternative means of communication for program
information (e.g., Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at
(202) 690-0443 (voice and TDD) or contact USDA through the Federal Relay Service at (800)
877-8339. Additionally, program information may be made available in languages other than
English.
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.

C.

AIP Marketing Materials
The following statement will be used on the AIP marketing materials: “The [Company] is an
equal opportunity provider.” or “[Recipient’s Organization name] is an equal opportunity
provider.” and “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, marital 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 activity conducted or funded by USDA (not all bases apply to all programs).”
Exceptions will only be made if the size of the material is too small to include the full statement.
The font size shall be the same for the following statement regardless: “[T]his institution is an
equal opportunity provider” or “[AIP Name] is an equal opportunity provider.”

June 2023

FCIC-24040

16

504

USDA Multiple Benefit Statement
AIPs must include the Multiple Benefit Statement on the acreage report.
Required 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.

505

Native Sod
AIPs must provide the Native Sod Statement to insureds in the states of Iowa, Minnesota, Montana,
Nebraska, North Dakota, and South Dakota, on or before the ARD for the current crop year.
Required Statement:
I understand that if I till native sod acreage, I will be assessed a reduction in yield guarantee and
premium subsidy, these reductions apply in the crop year that my total native sod acreage tilled
exceeds 5 acres in the county (cumulated across crops and crop years), and these reduction in benefits
may be retroactively applied within a crop year.

506

Conservation Compliance - Exception
A person (individual or legal entity) that began farming for the first time during the reinsurance year,
must sign the applicable conservation compliance certification statement to be eligible for this onetime exception (see Exhibit 3).
The certification statement must be signed by the later of the premium billing date or 60 days after a
transfer is approved for transferees who are the beneficiaries of a Transfer of Coverage and Right to
Indemnity or because of death, disappearance, or determined judicially incompetent.
The AIP must advise the insured that in order to qualify for the exemption, the insured is required to
sign one of the applicable conservation compliance certification statements to qualify for the
exemption. AIPs must maintain the signed certification statement in accordance with SRA record
retention requirements.

June 2023

FCIC-24040

17

507

Conditions of Acceptance Statement
The Application is accepted and insurance attaches in accordance with the policy unless:
(1)

FCIC determines that, in accordance with the regulations, the risk is excessive;

(2)

Any material fact is omitted, concealed, or misrepresented in the Application or in the
submission of the Application;

(3)

The applicant failed to provide complete and accurate information required by the Application;
or

(4)

An affirmative answer to any question appearing on the Conditions of Acceptance form.

See Exhibit 4.
508-600

June 2023

(Reserved)

FCIC-24040

18

PART 6: AIP REQUIRED STATEMENTS AND DISCLOSURES
601

Anti-Rebating Certification Statement
In accordance with Sec 508(a)(9) of the ACT and the SRA, a company and its affiliates are prohibited
from providing a rebate, except as authorized in Sec 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 Exhibit
6).

602

Covenant Not to Sue Statement (Covenant)
As defined in Sec 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 Sec 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. Below is 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.
Example Statement:
“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 and 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).”
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 Sec 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.

June 2023

FCIC-24040

19

602

Covenant Not to Sue Statement (Covenant) (Continued)
B.

Prior Reinsurance Year Covenant Acknowledgements
If existing Covenant acknowledgements executed in previous reinsurance years did not have
specific references, or any other terminology that would limit its effect to the previous
reinsurance year only, such acknowledgement may be considered effective for future
reinsurance years.
However, if existing acknowledgements of the Covenant have a reinsurance year limitation,
then a new acknowledgement without the reinsurance year 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.

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 have a 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 a 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 non-disclosure 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:

June 2023

(1)

A 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 a NDS from their employees
with access to Protected Information.

FCIC-24040

20

603

Non-Disclosure Statements (NDS) (Continued)
B.

AIP Annual Certification to RMA (Continued)
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 emailed to the assigned Reinsurance
Services Division Account Executive for the AIP.
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 NDSs must be retained by the
respective AIP, contractor, or affiliate and be available for inspection. Additionally, Para. 402
applies, see also Exhibit 7.

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
a 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 (see
Exhibit 8).
604

Conflict of Interest (COI) Disclosure Statements
All agents, loss adjusters, employees, and affiliates must submit an executed COI 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 AIP’s 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.

June 2023

FCIC-24040

21

604

Conflict of Interest (COI) Disclosure Statements (Continued)
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 indicated on the COI reports provided
by RMA are conducted. Agents are not permitted to assist the adjuster or assist the insured in any
manner regarding preparation of the claim, including without limitation, providing production by unit
for use in completing the MPCI claim forms. The agent is prohibited from accompanying the loss
adjuster to the field during MPCI claim activities. Elective reviews may be conducted by the AIP on
other business, financial, legal, or familial relationships not identified on the COI reports provided by
RMA. The chart provides a general reference guide (see also Exhibit 9).
A.

When the discloser is an Agent:
Positive Responses to Questions in
Disclosure

Prohibited Activity

AIP must ensure the Agent does NOT perform loss
Discloser performs both agent and loss
adjustment activities in same or adjoining
adjustment activities, possibly for
counties as those in which the agent performs
different AIPs.
sales activities, regardless of whether contracted
with the AIP or another AIP.
Sales agents, owners or employees of sales
Discloser has a share in a crop insured
agencies, sales supervisors, or any relative of the
under any eligible crop insurance policy
same shall not be involved in the acceptance and
insured by the AIP.
verification of underwriting data associated with
any crop insurance policy written by such person.
Sales agents, owners or employees of sales
Discloser has a relative with a substantial agencies, sales supervisors, or any relative of the
beneficial interest in any insurance
same shall not be involved in the acceptance and
policy insured by the AIP.
verification of underwriting data associated with
any crop insurance policy written by such person.
Discloser has power of attorney to act
The agent shall NOT perform those tasks in the
on behalf of an insured or is an
loss adjustment process on behalf of an insured
authorized representative of an insured
that are prohibited as specified by the GSH and
on any eligible crop insurance policy
SRA.
insured by the AIP.
Discloser has an ownership interest in a
Sales agents, owners or employees of sales
business (excluding stock in public
agencies, sales supervisors, or any relative of the
corporations or entities in which the
same shall not be involved in the acceptance and
discloser owns less than a ten percent
verification of underwriting data associated with
interest) with any insured by the AIP.
any crop insurance policy written by such person.
Sales agents, owners or employees of sales
Discloser has a rental or leasing
agencies, sales supervisors, or any relative of the
arrangement for land, buildings, or
same shall not be involved in the acceptance and
equipment with any insured.
verification of underwriting data associated with
any crop insurance policy written by such person.

June 2023

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22

604

Conflict of Interest (COI) Disclosure Statements (Continued)
A.

When the discloser is an Agent: (Continued)
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.

Prohibited Activity
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.

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.

Sales agents, owners or employees of sales
Discloser is a financial institution employee and agencies, sales supervisors, or any relative
part of the approval decision-making process
of the same shall not be involved in the
of financial arrangements for any insured by
acceptance and verification of underwriting
the AIP.
data associated with any crop insurance
policy written by such person.
Sales agents, owners or employees of sales
Discloser has an agent compensation, barter,
agencies, sales supervisors, or any relative
or financial arrangement (excluding those
of the same shall not be involved in the
reported under question 8. above) with any
acceptance and verification of underwriting
insured by the Company.
data associated with any crop insurance
policy written by such person.
Discloser is an owner/operator of a business or
a commission-based employee of a business,
Sales agents, owners or employees of sales
that provides goods or services not related to
agencies, sales supervisors, or any relative
farming operations, excluding insurance
of the same shall not be involved in the
services, for which the discloser receives
acceptance and verification of underwriting
revenue as the owner/operator or direct
data associated with any crop insurance
commission as an employee with respect to
policy written by such person.
any insured whose policy the discloser services
for the AIP.

June 2023

FCIC-24040

23

604

Conflict of Interest (COI) Disclosure Statements (Continued)
B.

When the discloser is an Adjuster:
Positive Responses to Questions in Disclosure

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 substantial beneficial
interest 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 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.
Discloser has a relative who works with the Federal crop
insurance program for the AIP or any of its affiliates.

June 2023

FCIC-24040

Prohibited Activity
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.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.

Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.

Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.
Prohibited from conducting any
loss adjustment activity on the
associated crop insurance policy.

24

604

Conflict of Interest (COI) Disclosure Statements (Continued)
C.

When the discloser is an employee who performs underwriting or loss adjustment activities
for the AIP:
Positive Responses to Questions in
Disclosure

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 an 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.
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.
June 2023

FCIC-24040

Prohibited Activity
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. The agent is not
permitted to assist the adjuster or the
insured in preparation of a claim. The agent
is prohibited from accompanying the loss
adjuster to the field during claim activities.
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.
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.
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.

25

604

Conflict of Interest (COI) Disclosure Statements (Continued)
C.

When the discloser is an employee who performs underwriting or loss…(Continued)
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 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.
Discloser has an agent compensation, barter,
or financial arrangement (excluding those
reported under question 8. above) with any
insured by the AIP.

Prohibited Activity

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.
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
Discloser has a business, familial, financial, or
acceptance and verification of underwriting
legal relationship that has not been identified
data or processing and verification of claim
above with any insured by the AIP.
data on the associated crop insurance policy.
Prohibited from involvement in the
Discloser has a relative who works with the
acceptance and verification of underwriting
Federal crop insurance program for the AIP
data or processing and verification of claim
or any of its affiliates.
data on the associated crop insurance policy.

605

Annual Controlled Business Certification
A.

General Information
Sec 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.

June 2023

FCIC-24040

26

605

Annual Controlled Business Certification (Continued)
A.

General Information (Continued)
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 Subpara. E.

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 than 30 percent from immediate family
polices, the individual is in violation of Sec 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 Sec 508(a)(10) will be subject to disqualification and civil fines
under the procedures implementing Sec 515(h) of the ACT, and any other procedures approved
by RMA implementing Sec 515(h). The gravity of the violation by the individual will determine
whether a sanction is imposed and if so, the type and amount.
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 they have an affiliation or from which they have received
compensation; however, certification concerns the aggregate of all direct and indirect
compensation from all AIPs with which the individual may have an affiliation.

June 2023

FCIC-24040

27

605

Annual Controlled Business Certification (Continued)
C.

Individual Annual Certification to AIP or Affiliate (Continued)
Example:

D.

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.

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:
(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.

This notification must be emailed to the assigned Reinsurance Services Division Account
Executive for the AIP.
F.

Individual Controlled Business Certification
If the AIP is collecting all of the Individual Controlled Business Certification forms, the AIP must
certify to RMA that it has collected all forms from those individuals required to submit an
Individual Controlled Business Certification (see Exhibit 10).

June 2023

FCIC-24040

28

605

Annual Controlled Business Certification (Continued)
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 (see Exhibit 11). 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.

606

Race, Ethnicity and Gender (REG) Disclosure Statement
All agents and loss adjusters must submit a REG Disclosure Statement to each AIP by whom they are
employed or with whom they are contracted. Unless there are changes or corrections, the REG
Disclosure Statement is only required to be submitted to each AIP once. New agents and loss adjusters
to an AIP must submit a REG Disclosure Statement within 15 days. If changes or corrections are
needed, the information must be submitted within 15 days of the discovery of the change or
correction.
Agents and loss adjusters may opt-out of the collection of this information in its entirety by selecting
the full “Opt-out” at the top of the form (if AIPs choose to use this element) or may opt-out in any
category by selecting, “Prefer not to respond”. If the full “Opt-out” is not selected or not used by the
AIP, then a selection must be made in each category for the form to be considered completed.
Whether or not any type of opt-out is selected, the REG Disclosure Statement must still be completed
and submitted by each agent and loss adjuster. The AIP must submit the REG Disclosure information
to RMA when required by Appendix III. The following are the categories and information to be
collected:
Race

Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or Pacific Islander
White
Other
Two or more races
Prefer not to respond

Ethnicity
Hispanic origin
Not of Hispanic origin
Prefer not to respond

Gender

Female
Male
Other
Prefer not to respond

AIPs may use electronic versions of the REG Disclosure Statement form, which incorporates either a
digital signature or an authentication system to properly identify the submitter. Electronic records of
signed or authenticated REG Disclosures must be retained by the respective AIP and be available for
inspection (see Exhibit 12 for the form standard).
607-700

June 2023

(Reserved)

FCIC-24040

29

FORM STANDARD EXHIBITS
Exhibit 1

June 2023

(Reserved)

FCIC-24040

30

Exhibit 2

June 2023

(Reserved)

FCIC-24040

31

Section 1: General Statements and Disclosures
Conservation Compliance - Exception

Exhibit 3

For the purposes of the conservation compliance statements, “farmed” means engaging in farming activities
as an owner, operator, tenant, or sharecropper and excludes others who do not meet these requirements
such as persons who solely participated in a farming operation as laborers or equipment operators.
Information about identifying and transmitting data regarding persons who meet this exception is available in
Appendix III. Each certification statement must be on a separate form, unless the AIP elects to combine forms.
A.

General Information
Item #
1
2
3
4
5
6

Element
“Applicant/Insured Name”
“Policy Number”
“Agent’s Name”
“Agent Code Number”
“Crop Year”
“Check One □ A □ B □ C □ D”
Note: Although a person may select any statement that is
applicable, the person must only select one certification
statement. These standards represent an all-in-one
form.

B.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive

Conservation Compliance Statement - Statement A
The following statement applies to either an individual that has not previously farmed preceding the
applicable reinsurance year or a legal entity in which none the SBIs of the legal entity have previously
farmed preceding the applicable reinsurance year.
Item #

Element

Statement “By signing below, I certify that:
A
1. I (name of individual or name of legal entity), hereafter referred
to as the policyholder, began farming for the first time on
(month and day), 20__;

Substantive/
Non-Substantive
Substantive

2. The policyholder, if an individual, had no interest, as an
individual or legal entity, in any land or commodity subject to the
Highly Erodible Land Conservation (HELC) or Wetland
Conservation (WC) provisions prior to the date contained in
paragraph (1);
3. The policyholder, if a legal entity, has no substantial beneficial
interest holders, as defined in section 1 of the Common Crop
Insurance Policy Basic Provisions (7 CFR § 457.8), that farmed
prior to the date contained in paragraph (1);
June 2023

FCIC-24040

32

Exhibit 3
B.

Conservation Compliance - Exception (Continued)

Conservation Compliance Statement - Statement A (Continued)
Item #

Element

Statement 4. The policyholder had no substantial beneficial interest, as
A (Cont.)
defined in 7 CFR Part 400, in any person who was subject to the
HELC or WC provisions prior to the date contained in paragraph
(1);

Substantive/
Non-Substantive
Substantive

5. The policyholder understands the Risk Management Agency and
the Farm Service Agency may review historical records to
determine prior participation in any USDA program or prior
interest in any land, crop or person that was subject to the HELC
or WC provisions;
6. The policyholder understands that if this certification is
determined to be false, the policyholder will be subject to
sanctions under the policy, including but not limited to voidance
of the policy, and the policyholder may be subject to 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).”
C.

Conservation Compliance Statement - Statement B
The following statement applies to a newly formed legal entity in which at least one of the SBIs of the
legal entity has farmed preceding the applicable reinsurance year. For a newly formed legal entity to
qualify for this exception, the legal entity must have been created for legitimate business purposes.
Item #

Element

Substantive/
Non-Substantive
Statement “By signing below, I, (name of individual), on behalf of (name of legal
Substantive
B
entity), hereafter referred to as the policyholder, certify that:
1. At least one substantial beneficial interest holder, as defined in
section 1 of the Common Crop Insurance Policy Basic Provisions
(7 CFR § 457.8), in the legal entity has farmed prior to signing
this certification;
2. The policyholder began farming for the first time on (month and
day), 20__;
3. The policyholder was organized as a legal entity such as a joint
venture, partnership, corporation, etc., for legitimate business
reasons such that its assets and liabilities generate economic
value regardless of USDA program benefits, and not to avoid
legal mandates regarding USDA program benefits including, but
not limited to, Highly Erodible Land Conservation (HELC) or
Wetland Conservation (WC) provisions;
June 2023

FCIC-24040

33

Exhibit 3
C.

Conservation Compliance - Exception (Continued)

Conservation Compliance Statement - Statement B (Continued)
Item #

Element

Statement 4. The policyholder understands the Risk Management Agency and
B (Cont.)
the Farm Service Agency may review historical records to
determine prior participation in any USDA program or prior
interest in any land, crop or person that was subject to the HELC
or WC provisions; and

Substantive/
Non-Substantive
Substantive

5. The policyholder understands that if this certification is
determined to be false, the policyholder will be subject to
sanctions under the policy(s), including but not limited to
voidance of the policy(s), and the policyholder may be subject to
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).”
D.

Conservation Compliance Statement - Statement C
The following statement applies to either an individual or legal entity that has never participated in a
USDA benefit program subject to the HELC or WC provisions, did not participate in Federal crop
insurance in the 2015 or subsequent reinsurance years as applicable, and has no prior interest in land
subject to HELC or WC provisions. In addition, the person cannot have an SBI or be an SBI who
participated in Federal crop insurance in the 2015 or subsequent reinsurance years, or in any other
USDA benefit program(s) subject to the HELC or WC provisions. Persons who received notification
from the Risk Management Agency or the Farm Service Agency that form AD-1026 may not be on file
with USDA are not eligible for this exception.
Item #

Element

Statement “By signing below, I certify that:
C
1. I (name of individual or name of legal entity), hereafter referred
to as the policyholder, have never participated in any USDA
benefit program(s) subject to the Highly Erodible Land
Conservation (HELC) or Wetland Conservation (WC) provisions;

Substantive/
Non-Substantive
Substantive

2. The policyholder has not participated in the Federal crop
insurance program in the 2015, or subsequent reinsurance years
prior to signing this certification;
3. The policyholder, if an individual, had no prior interest, as an
individual or legal entity, in any land or commodity subject to the
HELC or WC provisions;

June 2023

FCIC-24040

34

Exhibit 3
D.

Conservation Compliance - Exception (Continued)

Conservation Compliance Statement - Statement C (Continued)
Item #

Element

Statement 4. The policyholder has no substantial beneficial interest holder, as
C (Cont.)
defined in section 1 of the Common Crop Insurance Policy Basic
Provisions (7 CFR § 457.8), who participated in the Federal crop
insurance program in the 2015 or subsequent reinsurance years
prior to signing this certification, or in any other USDA benefit
program(s) subject to the HELC or WC provisions prior to signing
this certification;

Substantive/
Non-Substantive
Substantive

5. The policyholder had no substantial beneficial interest, as
defined in section 1 of the Common Crop Insurance Policy Basic
Provisions (7 CFR § 457.8), in any person who participated in
Federal crop insurance in the 2015 or subsequent reinsurance
years prior to signing this certification, or who was subject to the
HELC or WC provisions prior to signing this certification;
6. The policyholder has not received notification from the Risk
Management Agency or the Farm Service Agency that form AD1026 may not be on file with USDA certifying compliance with
the highly erodible land conservation HELC and WC provisions;
7. The policyholder understands the Risk Management Agency and
the Farm Service Agency may review historical records to
determine prior participation in any USDA program(s), including
Federal crop insurance, or prior interest in any land, crop or
person who participated in Federal crop insurance or who was
subject to the HELC or WC provisions; and
8. The policyholder understands that if this certification is
determined to be false, the policyholder will be subject to
sanctions under the policy, including but not limited to voidance
of the policy, and the policyholder may be subject to 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).”
E.

Conservation Compliance Statement - Statement D
The following statement applies to an individual (including a spouse) who may or may not have been
part of another legal entity engaged in farming preceding the applicable reinsurance year, who was an
SBI to a policyholder subject to the HELC or WC provisions, but who was not required to complete an
AD-1026 by FSA as an affiliated person on or prior to the beginning of the reinsurance year. Persons
who received notification from the Risk Management Agency or the Farm Service Agency that form AD1026 may not be on file with USDA are not eligible for this exception.

June 2023

FCIC-24040

35

Exhibit 3
E.

Conservation Compliance - Exception (Continued)

Conservation Compliance Statement - Statement D (Continued)
Item #

Element

Statement “By signing below, I certify that:
D
1. I (name of individual), hereafter referred to as the policyholder,
began farming as an individual for the first time on (month and
day), 20__;

Substantive/
Non-Substantive
Substantive

2. The policyholder has, or has previously held, a substantial
beneficial interest, as defined in 7 CFR Part 400, in a person who
was subject to the HELC or WC provisions prior to the date
contained in paragraph (1), but was not previously required to
sign form AD-1026;
3. The policyholder has not participated in the Federal crop
insurance program as a primary insured in the 2015 reinsurance
year, or subsequent reinsurance years as applicable, prior to
signing this certification;
4. The policyholder has not received notification from the Risk
Management Agency or the Farm Service Agency that form AD1026 may not be on file with USDA certifying compliance with
the highly erodible land conservation HELC and WC provisions;
5. The policyholder understands the Risk Management Agency and
the Farm Service Agency may review historical records to
determine prior participation in any USDA program or prior
interest in any land, crop or person that was subject to the HELC
or WC provisions; and
6. The policyholder understands that if this certification is
determined to be false, the policyholder will be subject to
sanctions under the policy, including but not limited to voidance
of the policy, and the policyholder may be subject to 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).”
F.

Required Signature and Statement
Item #

Element

1
2

“Applicant/Insured’s Printed Name, Signature and Date”
Privacy Act Statement

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Note: See Para. 503
June 2023

FCIC-24040

36

Exhibit 4

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 Questions
(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:

June 2023

For RI 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.”

FCIC-24040

37

Exhibit 5

Request for Administrative Reinstatement

This form is to be completed by the ineligible person requesting reinstatement and submitted to the Approved
Insurance Provider.
A.

Applicant Information
Item
#
1
2
3
4
5
6
7
8
9
10
11

B.

Element

Substantive/
Non-Substantive
“Name of Person Requesting Reinstatement”
Substantive
“Ineligible Person’s Identification Number”
Substantive
“Ineligible Person’s Identification Number Type”
Substantive
“Ineligible Person’s Street and/or Mailing Address”
Substantive
“City and State”
Substantive
“Zip Code”
Substantive
“Ineligible Person’s Telephone Number”
Substantive
“State and County”
Substantive
“Policy Number(s), if applicable”
Substantive
“Insured’s Identification Number (if not the same as the ineligible person)”
Substantive
“Insured’s Identification Number Type (if not the same as the ineligible
Substantive
person)”

Request Information
Item
Element
#
1
“Crop Year Reinstatement is Requested”
2
“Request Type (check one)
□ Unavoidable or Unforeseen Event
□ Weather Event
□ Medical Event

Substantive/
Non-Substantive
Substantive
Substantive/
Weather Event,
Medical Event,
and Other are
Non-Substantive

□ Other
□ Active Duty in U.S. Military
□ Failure to include All Amounts Due
□ Transposed Amount
□ 7-day Transit Period”

June 2023

FCIC-24040

38

Exhibit 5
B.

Request for Administrative Reinstatement (Continued)

Request Information (Continued)
Item
Element
#
3
“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.”
4

5

Note: Allow space for the Requestor to initial this statement.
“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.”
“I have attached the following documents:”

Substantive/
Non-Substantive
Substantive

Substantive

Substantive

Note: Allow space to include a list of supporting documentation.
C.

Required Statements
Item
Element
#
1
Insert the following statement above the Requestor’s signature line.
Allow space for the Requestor to initial this statement.

Substantive/
Non-Substantive
Substantive

“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.

2

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.”
Insert the following statement above AIP representative’s signature line.

Substantive

3

“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.”
Certification Statement

Substantive

Note: See Para. 502

June 2023

FCIC-24040

39

Exhibit 5
C.

Request for Administrative Reinstatement (Continued)

Required Statements (Continued)
Item
#
4
Privacy Act Statement
5

Element

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Note: See Para. 503
D.

Required Signatures
Item
#
1
2
3
4
5

Element
“Requestor’s Printed Name, Signature and Date”
“AIP’s Authorized Representative’s Printed Name, Signature and Date”
“AIP’s Authorized Representative’s Street and/or Mailing Address”
“AIP’s Authorized Representative’s Telephone Number”
“Insured’s Printed Name, Signature and Date”

Substantive/
Non-Substantive
Substantive
Substantive
Non-Substantive
Non-Substantive
Substantive

Note: Provide instruction that signature is to be obtained if the
Requestor is not the Insured.

June 2023

FCIC-24040

40

Section 2: AIP Statements and Disclosures
Anti-Rebating Certification

Exhibit 6

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 Para. 601 for more information regarding this certification.
A.

General Information
Item #

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Item #

Element

1
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 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.”

Substantive/
Non-Substantive
Substantive

1
2
3
4
5
B.

“Applicant/Insured Name”
“Policy Number”
“Agent’s Name”
“Agent Code Number”
“Crop Year”

Anti-Rebating Statement(s)

June 2023

FCIC-24040

41

Exhibit 6
B.

Anti-Rebating Certification (Continued)

Anti-Rebating Statement(s) (Continued)
Item #

Element

2
“I certify, for the crop year indicated, that I have neither offered nor
Agent
promised, directly or indirectly, any benefit, including money, goods,
Statement 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 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.”
C.

Required Signatures
Item #
1
2

D.

Substantive/
Non-Substantive
Substantive

Element
“Applicant/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

Substantive/
Non-Substantive
Substantive
Substantive

Required Statements
Item #

Element

1

Privacy Act Statement

2

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Note: See Para. 503

June 2023

FCIC-24040

42

Exhibit 7
A.

AIP Non-Disclosure Statement

General Information
Item
Element
#
1
“[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:

Substantive/
Non-Substantive
Substantive

(a) 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;
(b) 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

2
3

4
5

6

June 2023

(c) 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.”
“[INSERT COMPANY NAME] further agrees that it shall keep secure all
electronic and hard copy Protected Information.”
“[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.”
“[INSERT COMPANY NAME] certifies that it shall adhere to all security
policies and rules provided by RMA in handling USDA information and
systems.”
“[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).”
FCIC-24040

Substantive
Substantive

Substantive
Substantive

Substantive

43

Exhibit 7
A.

AIP Non-Disclosure Statement (Continued)

General Information (Continued)
Item
Element
#
7
Include the following definitions. See GSH for applicable definitions.

Substantive/
Non-Substantive
Substantive

“For the purposes of this document:
(a) Protected Information means…
(b) RMA means…
(c) USDA means…”
B.

Required Statement
Item
Element
#
1
“By having its authorized representative sign below, [INSERT COMPANY
NAME] acknowledges that it will adhere to all requirements for nondisclosure contained herein.”

C.

Substantive/
Non-Substantive
Substantive

Required Signature
Item
Element
#
1
“AIP Officer Printed Name, Signature and Date”
2
“AIP Officer’s Title”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

44

Exhibit 8
A.

Individual Non-Disclosure Statement

General Information
Item
Element
#
1
“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:

Substantive/
Non-Substantive
Substantive

(a) 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;
(b) 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

2

3

4
5

June 2023

(c) 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.”
“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).”

FCIC-24040

Substantive

Substantive

Substantive
Substantive

45

Exhibit 8
A.

Individual Non-Disclosure Statement (Continued)

General Information (Continued)
Item
Element
#
6
Include the following definitions. See the GSH for applicable definitions.

Substantive/
Non-Substantive
Substantive

“For the purposes of this document:”
(a) Protected Information means…
(b) Personally Identifiable Information means…
(c) RMA means…
(d) USDA means…”
B.

Required Statement
Item
#
1
Privacy Act Statement

Element

Substantive/
Non-Substantive
Substantive

Note: See Para. 501
C.

Required Signature
Item
Element
#
1
“Individual’s Printed Name and Signature and Date”
2
“Individual’s Title or Position”
3
“Name of affiliate or contractor, if applicable”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

46

Exhibit 9
A.

Conflict of Interest

General Information
Item #
1
2
3

Element
“Name and address of the discloser”
“Identification Number of the discloser”
“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:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

(a) Policy Sales
(b) Loss Adjustment
4

(c) Other (specify activity)”
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 AIP’s
discretion, this form may include additional information.

Substantive

(a) “Do you have a share in a crop insured under any eligible crop
insurance contract insured by the AIP?”
(b) “Do any of your relatives have a substantial beneficial interest in any
eligible crop insurance contract insured by the AIP?”
(c) “Do you have a power of attorney authorizing you to act as
attorney-in-fact or are you an authorized representative of a
policyholder with respect to any eligible crop insurance contract
insured by the AIP?”
(d) “Do you have an ownership interest in a business (excluding stock in
public corporations or entities in which you own less than a ten
percent interest) with any policyholder insured by the AIP?”
(e) “Do you have a rental or leasing arrangement for land, buildings, or
equipment with any policyholder insured by the AIP?”
(f) “Are you an owner/operator of a business or a commissioned based
employee that provides goods or services related to farming
operations (custom farming, tractor sales, etc., but 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?”

June 2023

FCIC-24040

47

Exhibit 9
A.

Conflict of Interest (Continued)

General Information (Continued)
Item #

Element

4
(g) “Are you an owner/operator of a business or a commissioned based
(Cont.)
employee that provides goods or services not related to farming
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?”

Substantive/
Non-Substantive
Substantive

(h) “Are you a financial institution employee and part of the approval
decision-making process of financial arrangements for any
policyholder insured by the AIP?”
(i) “Do you have an agent compensation, barter, or financial
arrangement (excluding those reported under question 8. above)
with any policyholder insured by the AIP?”
(j) “Do you have a business, familial, financial, or legal relationship that
has not been identified above with any policyholder insured by the
AIP?”
(k) “Do you have a relative who works with the Federal crop insurance
program, for the AIP, or any of its affiliates?”
B.

Required Statements
Item #

Element

1

“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.”
If a renewal COI, the AIP may create a check box with the following
statement:

2

3

“No previously disclosed information has changed from the information
contained in the 20XX disclosure.”
Privacy Act Statement

Substantive/
Non-Substantive
Substantive

Substantive

Substantive

Note: See Para. 501

June 2023

FCIC-24040

48

Exhibit 9
B.

Conflict of Interest (Continued)

Required Statements (Continued)
Item #
4

5

Element
“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.”
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive

Substantive

Note: See Para. 503
C.

Required Signature
Item #
1

June 2023

Element
“Discloser’s Printed Name, Signature and Date”

FCIC-24040

Substantive/Non-Substantive
Substantive

49

Exhibit 10

Individual Controlled Business Certification

This form utilized by the AIP must at a minimum include the following.
A.

General Information
Item
#
1
“Individual’s Name”
2
“Individual’s Title or Position”
3
“Identification Number”

B.

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Certification Statement
Item
Element
#
1
“For the [Insert the applicable reinsurance year] reinsurance year,
beginning July 1, 20XX, and ended June 30, 20XX.”
2
“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.”
3
Include the following definition. See GSH for applicable definitions.
4

“Immediate Family means…”
Include a check box for each option:

Substantive/
Non-Substantive
Substantive
Substantive

Substantive
Substantive

“Please certify to the following as it applies to you.
(a) 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.
(b) 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.”

June 2023

FCIC-24040

50

Exhibit 10
B.

Individual Controlled Business Certification (Continued)

Certification Statement (Continued)
Item
Element
#
5
Include check box for each option:

Substantive/
Non-Substantive
Substantive

“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:
(a) 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.
(b) 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.”
C.

Required Statements
Item
Element
#
1
“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.”
2
Privacy Act Statement
3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive

Substantive
Substantive

Note: See Para. 503
D.

Required Signature
Item
Element
#
1
“Individual’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
51

Exhibit 11

Affiliate Controlled Business Certification

This form utilized by the AIP must at a minimum include the following.
A.

General Information
Item
Element
#
1
“Affiliate’s Name”
2
“Officer or Owner’s Title or Position”

B.

Substantive/
Non-Substantive
Substantive
Substantive

Certification Statement
Item
Element
#
1
“For the [INSERT THE APPLICABLE REINSURANCE YEAR] reinsurance year,
beginning July 1, 20XX, and ended June 30, 20XX.”
2
“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).”
3
Include a check box for each option:

Substantive/
Non-Substantive
Substantive
Substantive

Substantive

“I hereby certify that one of the following is true and accurate:
(a) 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; or
(b) One or more individuals are not in compliance with the requirements
of section 508(a)(10)(B) of the Act because:
(i) The individual did not submit an “Individual Controlled Business
Certification”;
(ii) The individual certified the total amount of compensation
exceeded the amount allowed under section 508(a)(10)(B) of the
Act; or
(iii) 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.”

June 2023

FCIC-24040

52

Exhibit 11
B.

Affiliate Controlled Business Certification (Continued)

Certification Statemen (Continued)
Item
Element
#
4
“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 into 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].”

C.

Substantive/
Non-Substantive
Substantive

Required Signature
Item
Element
#
1
“Affiliate Officer’s Printed Name, Signature and Date”
2
“Affiliate Officer’s Title”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

53

Exhibit 12

REG Disclosure Statement

An AIP may have a stand-alone REG Disclosure Statement, or it may be combined with the Conflict of Interest
Disclosure. However, if a combined disclosure statement is used, all substantive items from both form
standards must be included in the combined disclosure statement.
A.

General Information
Item
#
1
2
3

4
B.

Element
“Name and address of the discloser”
“Identification Number of the discloser”
“AIP assigned code/AIP Identification number”

Substantive/
Non-Substantive
Substantive
Substantive
Non-Substantive

Note: Language/terminology for this item may be adjusted to reflect
the terminology used at the AIP.
Include boxes to check: “□ Agent □ Loss Adjuster”

Non-Substantive

REG Information
Item
#
1
“□

2

Element
Opt-out

By selecting the above box, I am opting out of providing all race, ethnicity
and gender information.”
Create a three-columned table for the following items. The column
headers must be “Race”, “Ethnicity”, and “Gender”. Include a check box
for each item in each column, and include the following statement above
the table:

Substantive/
Non-Substantive
Non-Substantive

Substantive

“Please select an option in each category below:”
(a) In the Race column include the following items:
“Asian, Black or African American, Native American or Alaska Native,
Native Hawaiian or Pacific Islander, White, Other, Two or more races,
Prefer not to respond”
(b) In the Ethnicity column include the following items:
“Hispanic origin, Not of Hispanic origin, Prefer not to respond”
(c) In the Gender column include the following items:
“Female, Male, Other, Prefer not to respond”
Note: See below for an example of the table.

June 2023

FCIC-24040

54

Exhibit 12
B.

REG Disclosure Statement (Continued)

REG Information (Continued)
Example table for Item 2:
Race

□
□
□
□
□
□
□
□
C.

Asian
Black or African American
Native American or Alaska Native
Native Hawaiian or Pacific Islander
White
Other
Two or more races
Prefer not to respond

Ethnicity
□ Hispanic origin
□ Not of Hispanic origin
□ Prefer not to respond

□
□
□
□

Gender
Female
Male
Other
Prefer not to respond

Required Statements
Item
#
1
Privacy Act Statement
2

3

Element

Note: See Para. 501
“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 the Standard
Reinsurance Agreement or ineligibility to participate in the Federal crop
insurance program.”
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Substantive

Note: See Para. 503
D.

Required Signature
Item
Element
#
1
“Discloser’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

55

Exhibit 13-15 (Reserved)

June 2023

FCIC-24040

56

Section 3: Policy Forms
Exhibit 16

Application

The Application is used to request insurance and must contain all 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.
A.

Applicant Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Element
“Applicant’s Name”
“Applicant’s Authorized Representative”
“Street and/or Mailing Address”
"City and State”
“Zip Code”
“Applicant’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”
“Is applicant at least 18 years old? Yes □ No □”
“Landlord/Tenant insuring other’s share”
Note: See Para. 411 and N/A for DRP policies.

B.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive

Crop Information
Item
#
1
2
3
4
5

6
7

Element
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
“Percentage Price Election, Projected Price, Amount of Insurance, or
Protection Factor”
Note: Substitute “Productivity Factor” for RI Applications. AIPs may
include only the applicable term for the appropriate plan of
insurance.
“Coverage Level”
“Practice”
Note: Item is only substantive if coverage level varies by practice.

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
Substantive/
Non-Substantive
57

Exhibit 16
B.

Application (Continued)

Crop Information (Continued)
Item
#
8
“Type”

Element

9
10

Note: Item is only substantive if coverage level varies by type.
“Plan of Insurance”
“Added County Election”

11

Note: See Para. 410
“Designated County” (for added county election only)

12

Note: See Para. 410
“Grid ID”

13

Note: Item is only substantive for API and PRF Applications.
“Index Interval”

14

Note: Item is only substantive for RI Applications.
“Percent of Value”
Note: Item is only substantive for RI Applications.

C.

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

Other Information
Item
Element
#
1
“Name of Previous AIP (if any)”
2
“Policy Number under Previous AIP (if any)”
3
“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.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Required Information:
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.)).

June 2023

FCIC-24040

58

Exhibit 16
C.

Application (Continued)

Other Information (Continued)
Item
Element
#
4
“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.”

Substantive/
Non-Substantive
Non-Substantive

Note: Allow space for the applicant to list all person(s) designated to
sign crop insurance documents on the applicant’s behalf.
D.

Required Statements
Item
Element
#
1
Conditions of Acceptance Statements

Substantive/
Non-Substantive
Substantive

2

Note: See Exhibit 4 and C3
Certification Statement

Substantive

3

Note: See Para. 502
Privacy Act Statement

Substantive

4

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item
Element
#
1
“Applicant’s Printed Name, Signature and Date” ***
2
“Agent’s Printed Name, Signature, Code Number and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

59

Exhibit 17

Supplemental Coverage Option Endorsement Application

Insureds 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.
A.

Applicant/Insured Information
Item #
1
2
3
4
5
6
7

B.

Element
“Applicant/Insured’s Name”
“Underlying Policy Number”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Identification Number”
“Identification Number Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item #
1
2
3
4
5
6
7
8

Element
“County Name”
“Crop(s)”
“Crop Year”
“Underlying Plan of Insurance”
“Coverage Level”
“SCO Plan of Insurance”
“ARC Coverage □ Yes □ No”
“Coverage percentage”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: Select from 50 percent to 100 percent. The default coverage
percentage is 100 percent.
C.

Terms and Conditions
Item #

Element

1

“In addition to Section 3(b)(2) of the Basic Provisions, I hereby elect this
Supplemental Coverage Option Endorsement and by this election I
understand:

Substantive/
Non-Substantive
Substantive

(a) 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 purchase this Endorsement with the
same Approved Insurance Provider as my Common Crop Insurance
Policy.

June 2023

FCIC-24040

60

Exhibit 17
C.

Supplemental Coverage Option Endorsement Application (Continued)

Terms and Conditions (Continued)
Item #

Element

1
(b) I may elect coverage under this Endorsement and the Farm Service
(Cont.)
Agency’s Agriculture Risk Coverage Program, but the same acreage
of the crop cannot be covered under both programs.

Substantive/
Non-Substantive
Substantive

(c) I may elect coverage under this Endorsement and Stacked Income
Protection Plan for the upland cotton, but the same acreage cannot
be insured under both.
(d) If at any time my Common Crop Insurance Policy for the crop is
canceled or terminated, coverage under this endorsement is
automatically canceled or terminated.
(e) 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 date or my coverage is otherwise canceled
or terminated under the terms of my policy.
(f) Separate Administrative Fees will be assessed for each crop insured
under this Endorsement.”
D.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signature
Item #
1
2

June 2023

Element
“Applicant/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

61

Exhibit 18

STAX Application

Insureds 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.
A.

Applicant Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Element
“Applicant’s Name”
“Applicant’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Applicant’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”
“Is applicant at least 18 years old? □ Yes □ No “
“Landlord/Tenant insuring other’s share”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: See Para. 411
B.

Crop Information
Item #

Element

1
2
3
4
5
6
7

“Crop”
“Effective Crop Year”
“State and County”
“Companion Policy Plan of Insurance, if applicable”
“Options, Elections, or Endorsements”
“Coverage Range”
“Practice”

8

Note: Item is only substantive if coverage level varies by practice.
“Type”

9
10
11
12

Note: Item is only substantive if coverage level varies by type.
“Area Loss Trigger”
“STAX Plan of Insurance”
“STAX Protection Factor”
“Added County Election”
Note: See Para. 410

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive

62

Exhibit 18
B.

STAX Application (Continued)

Crop Information (Continued)
Item #
13
14
15

C.

Element
“Designated County” (for added county election only)
Note: See Para. 410
“SCO and/or ECO Coverage □ Yes □ No”
“If yes, identify by APH Database whether SCO, ECO, 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 □ ECO □ STAX.”

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive

Other Information
Item #

Element

1
2
3

“Name of Previous AIP (if any)”
“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.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Required Information:
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.)).
D.

Terms and Conditions
Item #
1

June 2023

Element
“I may not elect coverage under this plan of insurance on the same
acres I elect coverage for the Supplemental Coverage Option
Endorsement (SCO) and/or the Enhanced Coverage Option (ECO) if I
participate in the SCO and/or ECO.

FCIC-24040

Substantive/
Non-Substantive
Substantive

63

Exhibit 18
D.

STAX Application (Continued)

Terms and Conditions (Continued)
Item #

Element

1
I may elect coverage under this plan of insurance and the Farm Service
(Cont.) Agency’s Agriculture Risk Coverage Program or Price Loss Coverage
Program, but the same acreage of the crop cannot be covered under
both programs.

Substantive/
Non-Substantive
Substantive

I understand that by signing this Application, the coverage under this
plan of insurance it 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.”
E.

Required Statements
Item
#
1

Element
“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.”

Substantive/
Non-Substantive
Non-Substantive

2

Note: Allow space for the applicant to list all person(s) designated to
sign crop insurance documents on the applicant’s behalf.
Conditions of Acceptance Statements

Substantive

3

Note: See Exhibit 4 and 3C
Certification Statement

Substantive

4

Note: See Para. 502
Privacy Act Statement

Substantive

5

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
F.

Required Signature
Item #
1
2

June 2023

Element
“Applicant’s Printed Name, Signature and Date” ***
“Agent’s Printed Name, Signature, Code Number and Date”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
64

Exhibit 19

BFR and VFR Application

A BFR/VFR Application is completed when an individual initially applies for BFR/VFR status; chooses to modify
the crop year(s) of insurable interest exceptions for BFR; or to correct a previously submitted BFR/VFR
Application. The BFR/VFR Application is required to be submitted by the applicable SCD. An AIP may have
separate Applications for BFR/VFR or they may be combined.
A.

Applicant Information
Item #
1
2
3
4
5
6
7
8

B.

Element
“Applicant’s Name”
“Applicant’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Applicant’s Telephone Number”
“Crop Year”
“Applicant’s Identification Number”
“Applicant’s Identification Number Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Beginning Farmer/Rancher Certification
Item #

Element

1

“I have produced the following crop(s) and/or livestock in the identified
State(s)/County(ies) during the time periods provided including any
USDA Agency/Program that you participated in for the crops/livestock:”

Substantive/
Non-Substantive
Substantive

Create a table with the following column headers: “From (MM/YY)”,
“To (MM/YY)”, “Type of Crop(s)/Livestock”, “State/County”, “Crop
Year”, and “USDA Program”

2

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. See example
table after item 3.
“I request the following Beginning Farmer/Rancher authorized
exclusions from consideration as crop years producing crop(s) or
livestock. I certify that I was:”

Substantive

Create a table with the following column headers: “Type of Exclusion”,
“From (MM/YY)”, “To (MM/YY)”, and “Crop Year(s)”; and the following
row headers under Type of Exclusion: “Under Age 18”, “Active
Military”, and “College”

June 2023

FCIC-24040

65

Exhibit 19
B.

BFR and VFR Application (Continued)

Beginning Farmer/Rancher Certification (Continued)
Item #

Element

2
(Cont.)

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. See example table after item 3.
“I am/am not (circle one) requesting to use the actual production
history from the previous producer for new acreage transferred to me.

3

Substantive/
Non-Substantive
Substantive

Substantive

If I have elected to use the actual production history from the previous
producer;
(a) I will provide the required documentation to prove that I was
previously involved in the decision making or the physical
activities necessary to produce crop(s) or livestock, the
documentation will also be specific as to which crop(s)/livestock
that I was previously involved with; and
(b) I will identify whose actual production history will be used and
the Farm/Tract and Field number of the acreage for the APH
information being transferred.”
Example Table for Item 1:
From
(MM/YY)

To (MM/YY)

Type of
Crop(s)/Livestock

State/County

Crop Year(s)

USDA
Program

Example Table for Item 2:
Type of Exclusion
Under Age 18
Active Military
College

June 2023

From (MM/YY)

FCIC-24040

To (MM/YY)

Crop Year(s)

66

Exhibit 19
C.

BFR and VFR Application (Continued)

Beginning Farmer/Rancher Additional Information
Item #
1

Element

Substantive/
Non-Substantive
Substantive

To be completed by the AIP “Eligible Number of Crop Years the BFR
applicant qualifies to receive BFR benefits_____ (____ for WFRP), this
number includes the crop year of BFR Application.”
Create a table with the following column headers: “Crop Years
Crop/Livestock Produced”, “Number of Years Producing
Crop/Livestock”, “Crop Years Excluded”, “Number of Years Excluded”,
“Number of Years when Determining BFR”

2

Note: 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. See example table
after item 2.
“Comments”

Substantive

Note: Allow space for comments to be written on the form.
Example Table for Item 1:
Crop Years
Crop/Livestock
Produced

Number of Years
Producing
Crop/Livestock

Crop Years
Excluded

Number of
Years
Excluded

Number of Year
when Determining
BFR

Total Years
D.

Veteran Farmer/Rancher Certification
Item #

Element

1

“I am a veteran, who served in the active military, naval, air, or space
service in the Armed Forces and was discharged or released under
conditions other than dishonorable in the Armed Forces.”
“I have operated a farm in the identified State(s)/County(ies) less than 5
years during the time periods provided including any USDA
Agency/Program that you participated in for the crops/livestock:”

2

Substantive/
Non-Substantive
Substantive
Substantive

Create a table with the following column headers: “From (MM/YY)”,
“To (MM/YY)”, “State/County”, “Crop Year”, and “USDA Program”
3

June 2023

Note: See example table after item 4.
“If qualifying for Veteran Farmer/Rancher based on being discharged
within the past 5 years, date of first discharge from active duty:
_____________________”
FCIC-24040

Substantive

67

Exhibit 19
D.

BFR and VFR Application (Continued)

Veteran Farmer/Rancher Certification (Continued)
Item #
4

Element
“I am/am not (circle one) requesting to use the actual production
history from the previous producer for new acreage transferred to me.

Substantive/
Non-Substantive
Substantive

If I have elected to use the actual production history from the previous
producer:
(a) I will provide the required documentation to prove that I was
previously involved in the decision making or the physical
activities necessary to produce crop(s) or livestock, the
documentation will also be specific as to which crop(s)/livestock
that I was previously involved with; and
(b) I will identify whose actual production history will be used and
the Farm/Tract and Field number of the acreage for the APH
information being transferred.”
Example Table for Item 2:
From (MM/YY)

E.

To (MM/YY)

State/County

Crop Year

USDA Program

Beginning Farmer/Rancher Required Statements
Item #

Element

1

“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 (10 years for
WFRP), 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:

Substantive/
Non-Substantive
Substantive

(a) as an individual;
(b) as an interest holder of at least 10 percent interest in another
person; and/or
(c) of any person(s) with an interest of at least 10 percent in me.
I understand that any inaccurate certification will result in recalculation
of my yield guarantees, administrative fee, premiums and any
applicable loss payments.”

June 2023

FCIC-24040

68

Exhibit 19
E.

BFR and VFR Application (Continued)

Beginning Farmer/Rancher Required Statements (Continued)
Item #

Element

2

“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.

Substantive/
Non-Substantive
Substantive

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.
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.”
F.

Veteran Farmer/Rancher Required Statements
Item #
1

Element
“As provided by me on this form, I certify that I (circle one)

Substantive/
Non-Substantive
Substantive

(a) have not operated a farm or ranch for more than five years; or
(b) am a veteran who first obtained status as a veteran during the
most recent five-year period.

2

June 2023

I understand that any inaccurate certification 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 VFR; 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 VFR to any
other AIPs that I may have a policy with in the current or subsequent
years.

FCIC-24040

Substantive

69

Exhibit 19
F.

BFR and VFR Application (Continued)

Veteran Farmer/Rancher Required Statements (Continued)
Item #

Element

2
I understand that if at any time following this Application, any changes
(Cont.) are made to the insured or substantial beneficial interest holder(s) to
the policy, it may affect my eligibility for Veteran Farmer/Rancher
benefits.

Substantive/
Non-Substantive
Substantive

I understand that if my policy has multiple substantial beneficial interest
holders, with the exception of a spouse, if applicable, or is insuring a
landlord/tenant’s share, all must qualify as Veteran Farmer/Ranchers
for benefits to apply.”
G.

Additional Information and Required Statements
Item #

Element

Substantive/
Non-Substantive
Substantive
Substantive

1
2

“New □, Amended Application □, or Cancellation □”
Certification Statement

3

Note: See Para. 502
Privacy Act Statement

Substantive

4

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
H.

Other Information and Required Signatures
Item #
1
2
3

June 2023

Element
“Applicant’s Printed Name, Signature and Date”
“Approved Insurance Provider’s (AIP) Name”
“AIP Representative’s Name, Signature and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

70

Exhibit 20

Policy Cancellation

The Policy Cancellation is to be used when the insured decides to cancel insurance coverage and is not
transferring coverage to another AIP.
A.

Insured Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12

B.

Substantive/ Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item #
1
2
3
4
5

C.

Element
“Insured’s Name”
“Insured’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”

Element
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
“Plan of Insurance”

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Cancellation Information
Item #
Element
1
“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.”

Substantive/Non-Substantive
Substantive

Note: This statement must be placed within a box
above the insured’s signature line and date.
D.

Required Statements
Item #
Element
1
Certification Statement

Substantive/Non-Substantive
Substantive

Note: See Para. 502
June 2023

FCIC-24040

71

Exhibit 20
D.

Policy Cancellation (Continued)

Required Statements (Continued)
Item #
2
Privacy Act Statement
3

Element

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/Non-Substantive
Substantive
Substantive

Note: See Para. 503
E.

Required Signature
Item #
Element
1
“Insured’s Printed Name, Signature and Date”
2
“AIP Authorized Representative’s Printed Name, Signature
and Date”

June 2023

FCIC-24040

Substantive/Non-Substantive
Substantive
Substantive

72

Exhibit 21

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.
A.

Applicant Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Element
“Applicant’s Name”
“Applicant’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Applicant’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”
“Is applicant at least 18 years old? Yes □ No □”
“Landlord/Tenant insuring other’s share”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: See Para. 411
B.

Crop Information
Item
#
1
2
3
4
5

June 2023

Element
“Effective Crop Year”
“Crop”
“State and County”
“Options, Elections, or Endorsements”
“Percentage Price Election, Projected Price, Amount of Insurance, or
Protection Factor”

6
7

Note: Substitute “Productivity Factor” for RI Applications. AIPs may
include the applicable term for the appropriate plan of
insurance.
“Coverage Level”
“Practice”

8

Note: Item is only substantive if coverage level varies by practice.
“Type”

9

Note: Item is only substantive if coverage level varies by type.
“Plan of Insurance”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
73

Exhibit 21
B.

Policy Transfer/Application (Continued)

Crop Information (Continued)
Item
#
10 “Added County Election”

Element

11

Note: See Para. 410
“Designated County” (for added county election only)

12

Note: see Para. 410
“Grid ID”

13

Note: Item is only substantive for API and PRF Applications.
“Index Interval”

14

Note: Item is only substantive for RI Applications.
“Percent of Value”
Note: Item is only substantive for RI Applications.

C.

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

Required Language for Request
Item
#
1
“Part I

2
3
D.

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Element

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/
Non-Substantive
Substantive

Substantive
Substantive

Required Language to Authorize and Signatures
Item
Element
#
1
“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].”
2
“Insured’s Printed Name, Signature and Date”
3
“Policy Number”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

Substantive
Substantive

74

Exhibit 21
E.

Policy Transfer/Application (Continued)

Required Language to Provide Insurance and Signatures
Item
#
1
“Part II

2
3
4
5
6
F.

Element

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.”
“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”

Substantive/
Non-Substantive
Substantive

Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

75

Exhibit 22

Policy Change

This form is to be used to make changes to the insurance policy without creating a new Application. Some
changes are required on or by a date specified in the policy. Some changes can be made at any time, such as
changing an insured’s physical address or adding an authorized representative (see GSH Para. 851).
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8

Element
“Insured’s Name”
“Insured’s Authorized Representative”
“State and County”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“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.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Information:
Name
Address
Telephone number
Identification Number
Identification Number Type
Person Type”

9

Note: Include a note regarding additional space if needed to
complete lists (e.g., (See reverse side for additional
space.)).
“Added County Election”

10

Note: See Para. 410
“Designated County” (for added county election only)
Note: See Para. 410

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive/
Non-Substantive

76

Exhibit 22
B.

Policy Change (Continued)

Changes to Insurance Coverage
Item
#
1

Element
“Change Insurance □”

2
3

Note: Form completion procedures must provide instructions to
check this box when appropriate.
“Effective Crop Year”
“Crop”

4

Note: For identification purposes only, a crop cannot be added using
a Policy Change.
“Practice”

5

Note: Item is only substantive if coverage level varies by practice.
“Type”

6

Note: Item is only substantive if coverage level varies by type.
“Percentage Price Election, Projected Price, Amount of Insurance, or
Protection Factor”

Substantive
Substantive

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive

7
8

Note: Substitute “Productivity Factor” for RI Applications. AIPs may
include the applicable term for the appropriate plan of
insurance.
“Coverage Level”
“Plan of Insurance”

Substantive
Substantive

9

Note: Plan of insurance cannot be changed using a Policy Change
between different plans of insurance that have different Basic
Provisions.
“Options, Elections, or Endorsements”

Substantive

10

Note: See Para. 413
“Grid ID”

11

Note: Item is only substantive for API and PRF Applications.
“Index Interval”

12

Note: Item is only substantive for RI Policy Change.
“Percent of Value”
Note: Item is only substantive for RI Policy Change.

C.

Substantive/
Non-Substantive
Substantive

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

Cancellations
Item
#
1
“Cancel Insurance □”

2
June 2023

Element

Note: Form completion procedures must provide instructions to
check this box when appropriate.
“Effective Crop Year”
FCIC-24040

Substantive/
Non-Substantive
Substantive

Substantive
77

Exhibit 22
C.

Policy Change (Continued)

Cancellations (Continued)
Item Element
#
3
“Crop”
4
“Options, Elections, or Endorsements”

5
6
7

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”
“Reasons for Cancellation”

Substantive/
Non-Substantive
Substantive
Substantive

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.
Example: (Check One - Explain selection in remarks)
□ Insured’s Request
□ Death, Incompetence, or Dissolution
□ Mutual Consent
□ Other
D.

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.
Item
Element
#
1
“Add or remove SBI”
2
“Add/change/correct insured’s authorized representative”
3
“Correct insured’s identification number”

June 2023

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

4
5

Note: Provide instruction for the insured to enter previous
identification number if item 3 is checked.
“Correct spelling of insured’s name”
“Correct SBI’s identification number”

Substantive
Substantive

6

Note: Provide instruction for the insured to enter previous
identification number if item 5 is checked.
“Correct the spelling of the SBI’s name”

Substantive

FCIC-24040

78

Exhibit 22
D.

Policy Change (Continued)

Other Changes (Continued)
Item
Element
#
7
“Add authority for designated person(s) to sign crop insurance documents
on behalf of the insured.”

Substantive/
Non-Substantive
Non-Substantive

“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.”

8

Note: Allow space for the insured to list all person(s) designated to
sign crop insurance documents on the insured’s behalf.
“Remove authority for designated person(s) to sign crop insurance
documents on behalf of the insured.”

Non-Substantive

Note: Allow space for the insured to list all person(s) whose authority
to sign crop insurance documents is removed.
E.

Remarks
Item
Element
#
1
Create a space to enter explanations and/or remarks

F.

Substantive/
Non-Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
G.

Required Signatures
Item
#
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date” ***
“Agent’s Printed Name, Signature, Code Number and Date”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
79

Exhibit 23
A.

Social Security Number and Employer Identification Number Reporting

Applicant/Insured’s Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12

B.

Element
“Applicant/Insured’s Name”
“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”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Other Person(s) Information
Item #

Element

1

“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.

Substantive/
Non-Substantive
Substantive

Required Information:
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.)).

June 2023

FCIC-24040

80

Exhibit 23
C.

Social Security Number and Employer Identification Number Reporting (Continued)

Required Signatures
Item #
1
2
3

D.

Element
“Applicant/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”
“Agent’s Street and/or Mailing Address”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

81

Exhibit 24

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 Acreage Report
instructions.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14

B.

Element
“Insured’s Name”
“Insured’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Landlord/Tenant insuring other’s share”
Note: See Para. 411
“Spouse’s Name”
“Spouse’s Identification Number
“Spouse’s Identification Number Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item
#
1
2
3
4

Element
“Crop Year”
“Crop”
“State and County”
“MCEU Other County”

5

Note: Item is only substantive when MCEU applies to the policy.
“MCEU Primary or Secondary County”

6
7

Note: Item is only substantive when MCEU applies to the policy.
“Plan of Insurance”
“Options, Elections, or Endorsements”

8
9
10

Note: Item is non-substantive for API and PRF acreage reports only.
“Type”
“Practice”
“Unit Number”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive
82

Exhibit 24
B.

Acreage Report (Continued)

Crop Information (Continued)
Item
#
11 “Unit Structure Code”

Element

12
13

Note: Item is non-substantive for RI Acreage Reports only.
“Coverage Level”
“Acreage Type”

14

Note: Item is non-substantive for RI Acreage Reports only.
“Legal Description:
_____ Section:

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

_____ Township:
_____ Range:
_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
15

Note: Item is non-substantive for RI Acreage Reports only.
“Field Location Identification”

16

Note: See CIH Para. 1211
“Approved Yield”

17

Note: Item is only substantive for those plans that use approved
yields.
“Reported Acres”

18
19
20
21
22
23

Note: Or “Number of Trees”, “Number of Pounds”, or “Insured Acres
by Grid”
Divide column and label “Whole” and “10ths or 100ths” underneath
“Reported Acres/Number of Trees or Pounds”
“Measurement Service”
“Insured’s Share”
“Name of Other Person(s) Sharing in the Crop”
“Date Planting Completed”
“Area Classification”

25

Note: Item is non-substantive for RI Acreage Reports only.
“Percentage Price Election, Projected Price, or Amount of Insurance, or
Protection Factor”
“Latitude and Longitude of the Point of Reference”

26

Note: Item is only substantive for API and PRF Applications.
“Grid ID”

24

Note: Item is only substantive for RI Applications.
June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive

Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

83

Exhibit 24
B.

Acreage Report (Continued)

Crop Information (Continued)
Item
#
27 “Intended Use”

C.

Element

28

Note: Item is only substantive for RI Applications.
“Total Insurable Acres”

29

Note: Item is only substantive for PRF: Total Insurable Acres of the
crop in which the insured has a share.
“Total Number of Colonies in the U.S.”

30

Note: Item is only substantive for API. Total number of colonies in
which the insured has a share.
“Total Number of Hives of Insured Colonies”

31

Note: Item is only substantive for API. Number of Hives of insured
colonies assigned to the Grid ID.
“Dual Use Option”

32

Note: Item is only substantive for AF.
“Remarks”

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive

Required Statements
Item
Element
#
1
Provide the following question above the Certification Statement.

2

3

“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.”
Substantive only for those policies that use an approved yield to establish
the guarantee. Provide the following Certification Statement above the
Agent’s signature.
“I certify that I am responsible for establishing the approved yields that
are used to calculate the production guarantees contained in this acreage
report and that such approved yields are correct to the best of my
knowledge.”
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/
Non-Substantive
Non-Substantive

Substantive/
Non-Substantive

Substantive/
Non-Substantive

“I □ HAVE or □ HAVE NOT broken native sod after February 7, 2014. For
any native sod acreage broken after December 20, 2018, identify the year
it was broken separately for each parcel: ____________________.”
June 2023

FCIC-24040

84

Exhibit 24
C.

Acreage Report (Continued)

Required Statements (Continued)
Item
Element
#
4
Substantive for Apiculture Only. Provide the following Statements above
the Insured’s signature on Acreage Reports subject to the Apiculture
Provisions:

Substantive/
Non-Substantive
Substantive/
Non-Substantive

“The colonies noted above qualify as apiculture and the selected index
intervals support the vegetation production necessary for the colonies.”

5

6

7

“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.”
Substantive for Annual Forage only. Provide the following Statement
above the Insured’s signature on Acreage Reports subject to the Annual
Forage Provisions:
“I certify that the acreage reported for the dual use option is intended to
be grazed.”
Substantive for Organic producers only. Provide the following Statement
above the Insured’s signature on Acreage Reports subject to the Organic
Provisions:
“I certify that I have an organic system plan, or organic certificate in place
or that I have provided a written request for an updated plan or certificate
to the certifying agent for all acreage reported as certified organic or
transitional organic.”
“I acknowledge that I must notify my agent if I intend to direct market any
portion of the crop or if my production records are not from a
disinterested third party.

Substantive/
Non-Substantive

Substantive/
Non-Substantive

Substantive

This notification to my agent must be made by the Acreage Reporting
Date, or if my marketing plans change after the Acreage Reporting Date,
no later than 15 days prior to harvest.
The notification may either be in person or by telephone and must be
certified in writing on the Marketing Certification within 15 days of
notification.

8

If I fail to timely provide the required certification and do not have
acceptable production records, it may result in assigned yields in
accordance with section 3(g) of the Common Crop Insurance Policy Basic
Provisions (7 CFR § 457.8).”
USDA Multiple Benefit Certification Statement

Substantive

Note: See Para. 504
June 2023

FCIC-24040

85

Exhibit 24
C.

Acreage Report (Continued)

Required Statements (Continued)
Item
#
9
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

10

Note: See Para. 502
Privacy Act Statement

Substantive

11

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
D.

Required Signatures
Item
#
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

86

Exhibit 25

Summary of Coverage (Schedule of Insurance)

This form is issued to the insured after the crop(s) is planted, reports their 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.
A.

Insured Information
Items (9) through (13) are non-substantive if the Policy Confirmation (Declaration) is sent every year to
the insured.
Item
#
1
2
3
4
5
6
7
8
9

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”

10

“SBI’s Name”

11

“SBI’s Identification Number”

12

“SBI’s Identification Number Type”

13

“SBI’s Person Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive

Crop Information
Item
Element
#
1
“Crop Insured”
2
“Crop/Practice/Type”
3
“Percentage Price Election, Projected Price, Amount of Insurance, or
Protection Factor”

4
5
6
7
8
June 2023

Note: Substitute “Productivity Factor” for RI Applications. AIPs may
include the applicable term for the appropriate plan of
insurance.
“Coverage Level”
“Options, Elections, or Endorsements”
“Effective Crop Year”
“Plan of Insurance”
“State and County”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Substantive
Substantive
Substantive
Substantive
Substantive
87

Exhibit 25
B.

Summary of Coverage (Schedule of Insurance) (Continued)

Crop Information (Continued)
Item
Element
#
9
“Multi-County Enterprise Unit applies to county. Name of Other County”

C.

10

Note: Item is only substantive when MCEU applies to policy.
“Policy Number for Other County”

11

Note: Item is only substantive when MCEU applies to policy.
“Total Guarantee of MCEU”

12
13
14
15

Note: Item is only substantive when MCEU applies to policy.
“Guarantee or Amount of Coverage”
“Liability”
“Insured’s Premium”
“Insurable Acres”

16

Note: Item is only substantive for RI.
“Insured Acres”

17

Note: Item is only substantive for RI.
“Insured’s Share”

18

Note: Item is only substantive for RI.
“Grid ID”

19

Note: Item is only substantive for RI.
“Index Interval”

20

Note: Item is only substantive for RI.
“Trigger Grid Index”

21

Note: Item is only substantive for RI.
“FSA Farm Number, Tract and Field”

22

Note: Item is only substantive for RI.
“Policy Protection per Unit”

23

Note: Item is only substantive for RI.
“Percent of Value”

24

Note: Item is only substantive for RI.
“Intended Use”

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive

Agent Information
Item
#
1
2
3
4

June 2023

Element
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
88

Exhibit 25
C.

Summary of Coverage (Schedule of Insurance) (Continued)

Agent Information (Continued)
Item
#
5
“Agent’s Code Number”
6
“Agent’s Telephone Number”

D.

Element

Substantive/
Non-Substantive
Substantive
Substantive

Other Information
Item
Element
#
1
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:

Substantive/
Non-Substantive
Substantive

“*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.”

2
3
4

June 2023

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.
“Date Issued”
“Amount of Administrative Fee Due the Approved Insurance Provider”
“Amount of Subsidy Paid by RMA”

FCIC-24040

Substantive
Substantive
Substantive

89

Exhibit 26

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.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”
“SBI’s Name”
“SBI’s Identification Number”
“SBI’s Identification Number Type”
“SBI’s Person Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item
#
1
2
3

Element
“Crop Insured”
“Crop/Practice/Type”
“Percentage Price Election, Projected Price, Amount of Insurance, or
Protection Factor”

4
5
6
7
8
9

Note: Substitute “Productivity Factor” for RI Applications. AIPs may
include the applicable term for the appropriate plan of
insurance.
“Coverage Level”
“Options, Elections, or Endorsements”
“Effective Crop Year”
“Plan of Insurance”
“State and County”
“Grid ID”

10

Note: Item is only substantive for RI Applications.
“Index Interval”

11

Note: Item is only substantive for RI Applications.
“Percent of Value”
Note: Item is only substantive for RI Applications.

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive/
Non-Substantive
90

Exhibit 26
C.

Policy Confirmation (Policy Declaration) (Continued)

Agent Information
Item
#
1
2
3
4
5
6

June 2023

Element
“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”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

91

Exhibit 27

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 COI requirements contained in the SRA (see the GSH).
A.

Required Language
Item
Element
#
1
“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].

Substantive/
Non-Substantive
Substantive

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:
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.
Providing program required production reports.
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].”

June 2023

FCIC-24040

92

Exhibit 27
B.

Power of Attorney (Continued)

Required Signatures
Item
#
1
2
3
4

C.

Element
“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”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Acknowledgement Block
Item
#
1
Example:

Element

Acknowledgement

Substantive/
Non-Substantive
Substantive/
Non-Substantive

[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], 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.
Note: Use the acknowledgment block if required by the State where
acknowledgment is taken.
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.
The acknowledgement may be modified for various person
types, (e.g., corporation, partnership, LLC), to be contractually
consistent with state law.

2

Signatures of the insured and the appointee must be notarized
when required by law. Witness signatures are not required, if
notarized, unless otherwise required by state law.
“Notary Seal and Signature of Notary”
Note: Substantive, as required by state law.

June 2023

FCIC-24040

Substantive/
Non-Substantive

93

Exhibit 27
D.

Power of Attorney (Continued)

Required Statements
Item
#
1
Privacy Act Statement
2

Element

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Note: See Para. 503

June 2023

FCIC-24040

94

Exhibit 28

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 (see the GSH).
A.

Insured Information
Item #
1
2
3
4
5
6
7

B.

Element
“Insured’s Name”
“Insured’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Policy Number”
“Effective Crop Year”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item #
1

Element
The assignment must read as follows:

Substantive/
Non-Substantive
Substantive

“The Insured assigns to [NAME OF CREDITOR] of [MAILING ADDRESS]
[CITY, STATE and ZIP] the right and interest of any indemnity payment(s)
which may be payable to the insured under the insurance policy for the
county/commodity(ies) shown:” e.g., [1ST CROP NAME AND COUNTY
NAME] [2ND CROP NAME AND COUNTY NAME]”

2

Note: The Name and Address of Creditor must be contained in the
above statement unless listed on the form.
“Conditions”

Substantive

(a) “This assignment will be binding upon the person(s) who succeed
the insured’s interest in the insurance policy.”
(b) “Indemnity payments made under the insurance policy will be
subject to a deduction for any indebtedness due this Approved
Insurance Provider by the insured.”
(c) “This assignment will not grant the Creditor any greater rights than
originally held by the insured.”
(d) “The Creditor’s interest will be recognized upon Approved Insurance
Provider’s approval of this assignment and the Creditor will have the
right to submit the loss notices and other forms as required by the
insurance policy.”

June 2023

FCIC-24040

95

Exhibit 28
B.

Assignment of Indemnity (Continued)

Terms and Conditions (Continued)
Item #

Element

2
(e) “The Approved Insurance Provider will determine the person(s)
(Cont.)
entitled to any indemnity payment(s) and the payment(s) will be by
joint check.”

Substantive/
Non-Substantive
Substantive

(f) “Cancellation of this assignment prior to and during the crop year
stated above will be accepted by the Approved Insurance Provider
only upon notification in writing by the above identified Creditor(s).
It is understood and agreed that this assignment will be subject to
the terms and conditions of the insurance policy.”
Note: Followed by signatures of the Insured, Creditor and
Witnesses if applicable, see Subpara. D for witness
requirements.

3
C.

(g) “If the assignment is not canceled according to item (f), the
assignment will cease at the end of the effective crop year.”
“This assignment was filed with the Approved Insurance Provider on
[MONTH], [DAY], [YEAR] at [INSERT HOUR] a.m./p.m.”

Substantive

Required Statements
Item #

Element

1

Privacy Act Statement

2

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Note: See Para. 503
D.

Required Signatures
Item #
1
2

June 2023

Element

3
4

“Insured’s Printed Name, Signature and Date”
“Creditor’s Authorized Representative Printed Name, Signature and
Date”
“Creditor’s Authorized Representative’s Telephone Number”
“Witness Printed Name, Signature and Date”

5

Note: The Creditor’s signature and date as provided in item D(2)
must contain a Witness signature and date. The insured’s
signature and date as provided in item D(1) may also
require a Witness signature and date. See GSH Para. 852 for
signature/witness requirements.
“AIP’s Authorized Representative Printed Name, Signature and Date”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
96

Exhibit 29
A.

Continuous Hail and Fire Exclusion Option

Insured Information
Item #
1
2

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”

Crop Information
Item #
1
2
3
4

C.

Substantive/
Non-Substantive
Substantive
Non-Substantive

Element
“The Hail and Fire Exclusion Option applies to the following crop(s):”
“State and County Where Insurance Attaches”
“Policy Number”
“First Effective Crop Year”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item #

Element

1

“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.

2

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).”
“To exclude hail and fire insurance, for the first crop year of this
option:”

Substantive/
Non-Substantive
Substantive

Substantive

(a) “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 multiseason 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.”
(b) “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.”

June 2023

FCIC-24040

97

Exhibit 29
C.

Continuous Hail and Fire Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #

Element

2
(c) “For each crop year, Hail and Fire insurance coverage must be in
(Cont.)
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.”

Substantive/
Non-Substantive
Substantive

(d) “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.”
(e) “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.”
(f) “The appraised amount of production is determined by:
(i) Subtracting the crop insurance policy coverage level from 1.00;
(ii) Subtracting the result of (a) from the percentage of hail and/or
fire damage;
(iii) Multiplying the result of (b) by the production guarantee per
acre for the applicable crop insurance policy; and

3

June 2023

(iv) 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.
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)

FCIC-24040

Non-Substantive

98

Exhibit 29
C.

Continuous Hail and Fire Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #

Element

3
Step 3:
(Cont.)

0.10 (excess percentage) × 100.0 bu. (per-acre guarantee) =
10.0 bushels

Substantive/
Non-Substantive
Non-Substantive

Step 4:
4

10.0 bu. ÷ 0.65 (crop insurance coverage level) = 15.4 bu.
per-acre appraisal for uninsured causes.”
“Except that:

Substantive

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.”
D.

Other Information
Item #
1

Element
“Information for the first-year hail and/or fire exclusion request.”

Substantive/
Non-Substantive
Substantive

(a) “Hail and Fire Coverage Effective Date”

2
3

(b) “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.

June 2023

FCIC-24040

99

Exhibit 29
E.

Continuous Hail and Fire Exclusion Option (Continued)

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
F.

Required Signatures
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

100

Exhibit 30
A.

Annual Request for Hail and Fire Exclusion Option

Insured Information
Item #
1
2

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”

Crop Information
Item #
1
2
3
4

C.

Substantive/
Non-Substantive
Substantive
Non-Substantive

Element
“The Annual Request to Exclude Hail and Fire applies to the following
crop(s):”
“State and County Where Insurance Attaches”
“Policy Number”
“Effective Crop Year”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item #
1

2

Element
“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.”
“For the effective crop year of this request:”

Substantive/
Non-Substantive
Substantive

Substantive

(a) “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 multiseason 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 Annual
Request to Exclude Hail and Fire on or before the date your crop
insurance coverage attaches for a crop year.”
(b) “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.”
(c) “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.”

June 2023

FCIC-24040

101

Exhibit 30
C.

Annual Request for Hail and Fire Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #

Element

2
(d) “You must provide a copy of the private hail and fire declaration
(Cont.)
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.”

Substantive/
Non-Substantive
Substantive

(e) “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.”
(f) “The appraised amount of production is determined by:
(i) Subtracting the crop insurance policy coverage level from 1.00;
(ii) Subtracting the result of (a) from the percentage of hail and/or
fire damage;
(iii) Multiplying the result of (b) by the production guarantee per
acre for the crop insurance policy; and

3

(iv) 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.
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) × 100.0 bu. (per-acre guarantee) =
10.0 bushels

Non-Substantive

STEP 4:
4

June 2023

10.0 bu. ÷ 0.65 (crop insurance coverage level) = 15.4 bu.
per-acre appraisal for uninsured causes.”
“Except that:
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.”
FCIC-24040

Substantive

102

Exhibit 30
D.

Annual Request for Hail and Fire Exclusion Option (Continued)

Other Information
Item #
1

Element
“Information for the first-year hail and/or fire exclusion request.”

Substantive/
Non-Substantive
Substantive

(a) “Hail and Fire Coverage Effective Date”

2
3

(b) “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.
E.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
F.

Required Signatures
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

103

Exhibit 31

High-Risk Land Exclusion Option

The CCIP 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 highrisk land at an increased cost reflective of the increased risk. Insureds who do not wish to insure high-risk land
or wish to insure their high-risk land at a lower level of coverage than their additional coverage policy (base
policy) may execute a HRLEO on or before the applicable SCD with the same AIP from which their additional
coverage was obtained. The HRLEO is elected on a policy basis and available for land located in high-risk areas
identified in the actuarial documents. See CIH for further instruction regarding this option.
A.

Insured’s Information
Item #
1
2
3
4
5
6
7
8
9

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“State and County”
“Identification Number”
“Identification Number Type”

Crop Information
Item #
1
2
3

C.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Element
“Crop(s)”
“Crop Year”
“Plan of Insurance or Percentage of Price”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Create check boxes for Items 2, 3 and 4 with instructions for the insured to select one.
Item #

Element

1

“I hereby elect this High-Risk Land Exclusion Option (HRLEO), and by this
election I understand:

Substantive/
Non-Substantive
Substantive

(a) I must have purchased an additional coverage policy under the CCIP
and applicable Crop Provisions (CP).
(b) 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). This
option only applies in those counties where high-risk land is
specified.

June 2023

FCIC-24040

104

Exhibit 31
C.

High-Risk Land Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #

Element

1
(c) That by signing this option it will continue from year to year unless I
(Cont.)
or [Insert AIP Name] 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.

Substantive/
Non-Substantive
Substantive

(d) If I transfer my policy to a different Approved Insurance Provider
(AIP), a new HRLEO must be signed by me and submitted to the new
AIP on or before the applicable SCD.
(e) If I choose to exclude coverage for high-risk land under the base
policy and not insure the high-risk land, those acres must be
reported as uninsured acreage on the acreage report. Separate
production records showing planted acreage and harvested
production from the high-risk land not insured must also be
maintained and reported by me on the production report. In the
event of a loss on any insured unit, I must provide separate
production records showing planted acreage and harvested
production for any acreage which is excluded from crop insurance
coverage under this option.
(f) When high-risk land is insured on a separate CAT or high-risk policy:
(i) it is considered a separate crop for: administrative fees, unit
division, added land, and all other insurance purposes. For yield
floor and variable T-Yield percentages, use the total number of
years of actual/assigned yields by crop/county for both policies.
(ii) The acreage and production from high-risk land insured on a CAT
policy or high-risk policy must be reported.
(A) The acreage of the crop planted on high-risk land insured on
a separate policy must be reported on the acreage report for
the policy insuring the high-risk land for each crop year.
(B) Separate production reports and supporting records
indicating planted acreage and harvested production for any
high-risk land insured on a separate policy are required.

2

June 2023

(g) All other provisions of the policy not in conflict with this option are
applicable.”
“By electing this option, if I chose to exclude coverage for the high-risk
land under the base policy and not insure the high-risk land on a
separate policy, I understand that I am declining crop insurance
coverage under the CCIP and the applicable CP for my high-risk land.”
FCIC-24040

Substantive

105

Exhibit 31
C.

High-Risk Land Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #
3

Element
“By electing this option, if I choose to insure high-risk land under a
separate CAT policy. I understand:

Substantive/
Non-Substantive
Substantive

(a) The CAT coverage for the high-risk land will be for yield protection
only, even if revenue coverage is elected for the base policy.
(b) I will have a CAT policy for my high-risk land and a base policy for my
non-high-risk land.
4

(c) WAs are not authorized for any policies insured under CAT.”
“By electing this option, if I choose to insure my high-risk land on a highrisk policy if available in the actuarial documents, I understand:

Substantive

(a) I must select a coverage level greater than Catastrophic Risk
Protection.
(b) I will have two additional coverage policies, a base policy covering
my non-high-risk land and a high-risk policy covering my high-risk
land.
(c) If my base policy is Yield Protection (YP), insurance for my high-risk
policy is limited to a YP policy with a lower coverage level.
(d) If I have a Revenue Protection (RP) policy, insurance for my high-risk
land is limited to a RP policy with lower level of coverage or a YP
policy with the same or lower coverage level.
(e) If I have a Revenue Protection with Harvest Price Exclusion (RP-HPE)
policy, insurance for my high-risk land is limited to limited to a RPHPE policy with lower level of coverage or a YP policy with the same
or lower coverage level.
(f) That any other options or endorsements elected on my base policy
will continue under this option.
(g) Unit structure is a separate choice for the base policy and high-risk
policy and applicable qualifications must be separately met for each
policy. Whole-farm units are not available on acreage that is
provided crop insurance coverage under this option.

June 2023

FCIC-24040

106

Exhibit 31
C.

High-Risk Land Exclusion Option (Continued)

Terms and Conditions (Continued)
Item #

Element

4
(h) Written Agreements (WAs) are not available on acreage that is
(Cont.)
provided crop insurance coverage under this option, except for
those WAs offering lower rates on the high-risk land and WAs for
unrated land for that crop in that county that meet the following
requirements:

Substantive/
Non-Substantive
Substantive

(i) that county must have the WA crop listed as an insurable crop in
the county at standard rates; and
(ii) the WA contains rates on the crop in excess of standard rates for
the county.”
D.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatured
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

107

Exhibit 32

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.
A.

Transferor Information
Item
#
1
2
3
4
5
6

Element
“Transferor’s Name”
“Transferor’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Policy Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:
_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
B.

Crop Information
Item
#
1
2
3
4
5

Element
“Crop(s)”
“Crop Year”
“Unit Number”
“Is the entire insured acreage and the entire insured share on this unit
being transferred? Yes □ No □”
Statement (a) below may be used alone. If both statements are used the
form should contain check boxes and indicate “Check one of the boxes.”
(a)

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

“Make check payable jointly to insured and transferee(s). Check
will be mailed to the insured’s address (unless an assignment of
indemnity is on file); or

(b)
6

“Make checks payable to transferee(s) only. Check will be mailed
to address shown for the transferee(s).”
“FSA Farm, Tract, Field Number”

7

Note: Item is only substantive for RI.
“Grid ID”
Note: Item is only substantive for RI.

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive/
Non-Substantive
108

Exhibit 32
B.

Transfer of Coverage and Right to an Indemnity (Continued)

Crop Information (Continued)
Item
#
8

Element
“Index Interval”
Note: Item is only substantive for RI.

C.

Transferee Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12

D.

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Element
“Transferee’s Name”
“Transferee’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Policy Number”
“Transferee’s Identification Number”
“Transferee’s Identification Number Type”
“Person Type”
“Acreage Transferred”
“Share Transferred”
“Effective Date of Transfer”
“Nature of Transfer”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item
Element
#
1
“Acceptance by the Approved Insurance Provider of the above-described
transfer shall transfer the insured’s right to an indemnity to the abovenamed transferee subject to:”

Substantive/
Non-Substantive
Substantive

(a) “Receipt by the Approved Insurance Provider of satisfactory evidence
that said transfer occurred before the end of the insurance period;
i.e.,: (1) the date harvest was completed on the unit; (2) the calendar
date for the end of the insurance period; or (3) the date the entire
crop on the unit was destroyed, as determined by the Approved
Insurance Provider.”
(b) “The terms of the above-identified insurance contract, including any
outstanding assignment of indemnity made by the transferor prior to
the date of transfer.”
2

June 2023

(c) “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.”
FCIC-24040

Substantive

109

Exhibit 32
D.

Transfer of Coverage and Right to an Indemnity (Continued)

Terms and Conditions (Continued)
Item
Element
#
3
“The insurance policy of the transferor covers the share hereby
transferred only to the end of the insurance period for the current crop
year.”
4
“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
□”
5
$_____
“Total premium on this unit”
6
$_____
“Premium on acreage transferred”
7
$_____
“Premium on retained acreage”
8
$_____
“Premium paid with transfer”

E.

Substantive/
Non-Substantive
Substantive
Substantive

Substantive
Substantive
Substantive
Substantive

Required Statements
Item
Element
#
1
This statement must appear above the signature line.

Substantive/
Non-Substantive
Substantive

2

“I, [INSERT TRANSFEREE’S NAME], the Transferee, understand that all
billing statements will only be issued to [INSERT TRANSFEROR’S NAME],
the Transferor. Due process/Ineligibility notification letters will be issued
to both the transferee and 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.”
Certification Statement

Substantive

3

Note: See Para. 502
Privacy Act Statement

Substantive

4

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
F.

Require Signatures
Item
#
1
2
3

June 2023

Element
“Transferor’s Printed Name, Signature and Date”
“Transferee’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

110

Exhibit 33
A.

Withdrawal of Claim for Indemnity

Insured Information
Item #
1
2
3
4
5

B.

Element

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Item #
Element
1
Withdrawal Statement

Substantive/Non-Substantive
Substantive

Terms and Conditions

2
C.

“Insured’s Name”
“Claim Number”
“Policy Number”
“Crop(s)”
“Unit Number(s)”

“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.”
“□
I am electing benefits under another USDA
program.”

Non-Substantive

Required Statements
Item #
1
Privacy Act Statement
2

Element

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/Non-Substantive
Substantive
Substantive

Note: See Para. 503
D.

Required Signatures
Item #
Element
1
“Insured’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/Non-Substantive
Substantive

111

Exhibit 34

Request for an RMA Assigned Identification Number

The Request for an RMA Assigned Identification Number form is applicable to insure individuals or individuals
with an SBI in the insured, as defined in the applicable policy provisions and GSH procedures, that are not
legally required to have an SSN or EIN number. Such individuals may be assigned an identification number
that can be used for insurance purposes.
Individuals requesting an RMA Assigned Identification 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. See the GSH for documentation
requirements for non-citizens and AIP instructions.
A.

Applicant Information
Item
#
1
2
3
4
5
6
7
8
9
10
11

12
13
B.

Element
“[YEAR] and Succeeding Crop Years”
“Applicant’s Name”
“Applicant’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“Policy Number (if applicable)”
“Identification Number of Insured (if request is for SBI)”
“Identification Number Type of Insured (if request is for SBI)”
“Insured’s Person Type (if request is for SBI)”
“Documentation Type”
Note: For example, Admitted for Permanent Residence, Admitted as
a Refugee, Asylee, etc. Provide instruction to “include a brief
list of all attached documentation (e.g., INS Form I-94).” See
the GSH.
“Is this request to renew a previously issued RMA Assigned Number?
Yes □ No □”
“If yes, list the previously issued RMA Assigned Number, the issue date
and the expiration date.”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
Substantive

Required Signatures
Item
#
1
2
3
4
5

June 2023

Element
“Applicant’s Printed Name, Signature and Date”
“Insured’s Printed Name, Signature and Date”
“AIP’s Authorized Representative’s Printed Name, Signature and Date”
“AIP’s Authorized Representative’s Street and/or Mailing Address”
“AIP’s Authorized Representative’s Telephone Number”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Non-Substantive
Substantive
112

Exhibit 34
C.

Request for RMA Assigned Identification Number (Continued)

Required Statements
Item
#
1

Element

Substantive/
Non-Substantive
This statement must appear above the AIP representative’s signature line.
Substantive

2

“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 an SSN/EIN.”
Certification Statement

Substantive

3

Note: See Para. 502
Privacy Act Statement

Substantive

4

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

113

Exhibit 35

Request to Waive Administration 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.
A.

Insured Information
Item #
1
2
3
4
5
6
7
8
9

B.

Element
“Insured’s Name”
“Insured’s Authorized Representative”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“County”
“Identification Number”
“Identification Number Type”
“Policy Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
The following statements are required.
Item #

Element

1

“I, [INSURED’S NAME], request that the administrative fee be waived for
the [YEAR] crop year.”
“I certify that:”

2

Substantive/
Non-Substantive
Substantive
Substantive

□ “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: Insert applicable dollar amount as specified at
lrftool.sc.egov.usda.gov; or this statement may be revised to
state “…sales not more than the amount specified by the
Natural Resource Conservation Service at
lrftool.sc.egov.usda.gov.”

June 2023

FCIC-24040

114

Exhibit 35
B.

Request to Waive Administration Fee for Limited Resource Farmer (Continued)

Terms and Conditions (Continued)
Item #

Element

2
□ “I was insured prior to the 2005 crop year, or was insured for the
(Cont.)
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.”
C.

Substantive/
Non-Substantive
Substantive

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
D.

Required Signatures
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“AIP Representative’s Printed Name, Signature and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

115

Exhibit 36

Unit Division Option

Agents will prepare a Unit Division Option and transmit to the AIP for verification. See CIH for form
completion instructions.
A.

Insured Information
Item #
1
2
3
4
5
6
7
8

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“Plan of Insurance”
“Policy Number”
“Crop Year”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item #

Element

1

“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:”

Substantive/
Non-Substantive
Substantive

(a) “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.”
(b) “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).”
(c) “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
years in which this option remains in effect.”
(d) “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).”
(e) “Determination of your optional units will be made at the time you
report your acreage of the insured crop.”
June 2023

FCIC-24040

116

Exhibit 36
B.

Unit Division Option (Continued)

Terms and Conditions (Continued)
Item #

Element

1
(f) “For crop(s) requiring production reports, to retain such optional
(Cont.)
units, acceptable production reports must be filed by the Production
Report Date, annually, for each optional unit.”

Substantive/
Non-Substantive
Substantive

(g) “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.”
C.

Other Information
Create a table with the following columns (1) through (3).
Item #
1
2
3
4

Element
“Optional Units”
“Descriptions of Designated Parcels of Land”
“Acres”
Include the following note below the table.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

“Note: A map identifying the above must be attached and numbered as
___ of ___ pages.”
D.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item #
1
2
3
4

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”
“Verified by”
“AIP Authorized Representative’s Printed Name, Signature and Date”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Note: Affix item (3) above AIP Authorized Representative’s
Signature.
June 2023

FCIC-24040

117

Exhibit 37

New Producer Certification

The New Producer Certification 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.
A.

Insured Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12

B.

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Element

Substantive/Non-Substantive
Substantive
Substantive

“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Telephone Number”
“Policy Number”
“State and County”
“Crop Year”
“Identification Number”
“Identification Number Type”
“SBI Identification Number”
“SBI Identification Number Type”

Crop Information
Item #
1
“Crop”
2
“Practice/Type”

C.

Element

New Producer Certification Statement
Item #
Element
1
“I certify that I have not produced the insured crop in the
county for more than two APH crop years.

Substantive/Non-Substantive
Substantive

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.

2

June 2023

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”

FCIC-24040

Substantive

118

Exhibit 37
D.

New Producer Certification (Continued)

Required Statements
Item #
Element
1
Certification Statement

Substantive/Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item #
Element
1
“Insured’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/Non-Substantive
Substantive

119

Exhibit 38

Unit Division by Grid Option (UDGO)

Agents will prepare a UDGO and transmit to the AIP by the earliest ARD for all insured Category B crops with
additional coverage in the insured’s operation for the crop year (all applicable insured crops) for verification.
See CIH for more information regarding the UDGO process.
A.

Insured Information
Item #
1
2
3
4
5
6
7

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“Policy Number”
“Crop Year”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Terms and Conditions
Item #

Element

1

“Upon our verification of this option, when your Federal Crop Insurance
Policy(ies) permit optional units (OUs), they will be established by RMA
Grid. The RMA Grid is based on the United States National Grid (USNG),
by dividing each USNG polygon (approximately 6.2-mile by 6.2-mile)
into 36 equal-sized polygons approximately 686 acres in size. These
approximately 686-acre polygons are each identified with a unique
Section Equivalent ID and will be considered section equivalent parcels
of land legally identified by other methods of measure, in accordance
with Federal Crop Insurance Corporation (FCIC) procedure for
establishing OUs. The following terms and conditions apply:”

Substantive/
Non-Substantive
Substantive

(a) “You are allowed one Unit Division by Grid Option (UDGO) per
county that covers all insured Category B crops with additional
coverage in your operation for the crop year (all applicable insured
crops). For all applicable insured crops, the UDGO elections must be
made by the representative Sales Closing Date (SCD) for each
applicable insured crop and submitted to us on or before the earliest
ARD for all applicable insured crops before it is effective. For
counties that have crop(s) with a fall or winter SCD and a spring SCD
specified in the actuarial documents, the UDGO election may be
changed on or before the earliest spring SCD for all applicable
insured crops if there is no insured fall or winter planted acreage of
any insured crop. If it is determined you have two or more UDGOs,
the UDGO with the earliest date will be applicable to all crops, and
the other UDGOs will be void.”

June 2023

FCIC-24040

120

Exhibit 38
B.

Unit Division by Grid Option (Continued)

Terms and Conditions (Continued)
Item #

Element

1
(b) “Each OU established under the UDGO will be comprised of the
(Cont.)
insurable cropland under the same basic unit (BU) considered to be
within a Section Equivalent ID. Each field, which is defined by the
Common Crop Insurance Policy, Basic Provisions (CCIP-BP) as all
acreage of tillable land within a natural or artificial boundary (e.g.,
road, waterways, fences, etc.), will be assigned to a single Section
Equivalent ID. Different planting patterns or planting different crops
do not create separate fields. For fields that cross grid boundaries,
the field will be assigned to the Section Equivalent ID in which the
centroid of that field lies. All fields under the same BU having a
centroid within the Section Equivalent ID will comprise the OU. OUs
established by UDGO can further be divided by irrigated and nonirrigated acreage and acreage insured under an organic farming
practice as provided in the CCIP-BP and as allowed in the applicable
Crop Provisions (CP). You are not required to have OU structure
when UDGO is elected and can still choose unit structure on a
crop/county basis for the current crop year.”

Substantive/
Non-Substantive
Substantive

(c) “For each OU, you must have acceptable records of acreage and
production for the previous crop year and maintain records for the
current crop year and succeeding crop years in which this option
remains in effect.”
(d) “Upon our request, if you fail to provide to us such records, OUs
created under this Option will revert to the BUs.”
(e) “Determination of your OUs will be made at the time you report
your acreage of the insured crop.”
(f) “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 earliest cancellation date for all applicable insured crops. All
other provisions of the policy not in conflict with this Option are
applicable.”
C.

Other Information
Create a table with columns for items (1) through (5). See an example table below item 7.
Item #
1
2
3

June 2023

Element
“Basic Unit”
“Optional Unit”
“Section Equivalent ID Assigned to Optional Unit”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
121

Exhibit 38
C.

Unit Division by Grid Option (Continued)

Other Information (Continued)
Item #

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

4
5
6

“List of Fields and Acres”
“Total Acres for the Optional Unit”
Include the following note below the table.

7

“Note: A digitized map identifying the above, including each field and
associated centroid, must be attached and numbered as _____ of _____
pages.”
“Policies with more than one AIP? Yes □ No □”

Example Table:
BASIC
UNIT
0001

Below an example of the unit and field information recorded on the UDGO:

OPTIONAL
UNIT

SECTION EQUIVALENT ID
ASSIGNED TO OPTIONAL
UNIT
TX-14RPV72-15

LIST OF FIELDS
AND ACRES

TOTAL ACRES FOR
THE OPTIONAL UNIT

1 - 23.2, 2 - 49.4, 200.2
6 - 14.8, 7 - 112.8
0002
TX-14RPV72-23
3 - 160.8, 4 - 110, 347
5 - 76.2
Note: A digitized map identifying the above, including each field and associated centroid, must be
attached and numbered as _____ of _____ pages.
D.

0001

Substantive

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item #
1
2
3
4

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”
“Verified by” must be affixed above item (4)
“AIP Authorized Representative’s Printed Name, Signature and Date”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
122

Exhibit 39-50 (Reserved)

June 2023

FCIC-24040

123

Section 4: Category B, C and D Forms
Exhibit 51
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

B.

RMA Regional Office Determined Yield Request

Element
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Agent Code Number”
“Telephone Number”
“Email”
“Insured Name (as shown on the Application)”
“Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“State”
“Policy Number”
“Crop Year”
“Identification Number”
“Identification Number Type”
“Insured is (check one):
□

Landlord

□

Operator

□

Owner/Operator”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Request Information
Create a table with the following columns in (2) through (13).
Item
Element
#
1
“Provide the following information for the request:”
2
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:
_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
June 2023

FCIC-24040

124

Exhibit 51
B.

RMA Regional Office Determined Yield Request (Continued)

Request Information (Continued)
Item
#
3
4
5
6
7
8
9
10
11
12

Element
“Crop”
“Unit Number”
“Whole Acres”
“Plant Date”
“FSA Farm/Tract/Field Number”
“Practice”
“Type/Class/Variety”
“Insured Share”
“Name of Other Person(s) Sharing in the Crop”
“Reason for this Request:”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: Create a checklist with the following items (a) through (b)(ix).
Instruct the requestor to select one of the reasons.
(a) “Category B Crop(s)”
(i) “Master Yield”
(ii) “New Producer and Variable T-Yield Exception”
(b) “Category C Crop(s), Florida citrus and Pecan Revenue”

June 2023

(i)

“Underage Crop (Category C Crop(s))”

(ii)

“Higher Yield Request (Category C Crop(s), Pecan Revenue)”

(iii)

“Change in Practice or Production Methods (Category C
Crop(s), Pecan Revenue)”

(iv)

“Alternate Bearing (Category C Crop(s))”

(v)

“Downward Trending (Category C Crop(s))”

(vi)

“Minimum Production Requirement (Category C Crop(s))”

(vii)

“Other When Authorized in writing by RMA (Category C
Crop(s))”

(viii)

“Productivity is Reduced (Category C Crop(s), Florida citrus,
Pecan Revenue)”

(ix)

“Irrigation Supply is Not Adequate (Category C Crop(s))”

FCIC-24040

125

Exhibit 51
B.

RMA Regional Office Determined Yield Request (Continued)

Request Information (Continued)
Item
Element
#
13 “Explain Reason(s) for Regional Office Determined Yield Request

Substantive/
Non-Substantive
Substantive

(a) Produced the crop on a farming operation for more than two crop
years, stopped farming ALL land in that farming operation and has
produced the crop on entirely different land for two APH crop years or
less, in the county (CIH 1731 (1)(a)).
(b) Has NOT produced or shared in the crop, in the county, in the most
recent 10 calendar years preceding the current crop year (11 calendar
years for crops with a lag year). If the insured produced or shared in
the crop for one or two years in the most recent 10 calendar years (11
calendar years for crops with a lag year), production reports must be
filed for such crop years (CIH 1731 (1)(b)).
(c) Other (explain)”
C.

Submission Documentation
Create a checklist with the following columns for items (2) through (10) for supplemental
documentation. All necessary supplemental documentation is contained in procedure.
Item
#
1
2
3
4
5
6
7
8
9
10

Element
“Check all that apply”
“Application/Policy Confirmation”
“Current APH Database, including Production Reports for unit(s)”
“Copy of Production Records substantiating any Crop Provisions
minimums that have been met - Category C Crops”
“APH Block Production - Category C Crops”
“Weighted Average Age/Density Worksheet(s) - Category C Crops”
“Producer’s Pre-Acceptance Worksheet(s) - Category C Crops, Florida
citrus and Pecan Revenue”
“Perennial Crop Pre-Acceptance Inspection Report - Category C Crops,
Florida citrus and Pecan Revenue”
“Master Yield Summary APH Database - Category B Crops”
“Other”

Substantive/
Non-Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: Including other required documents per the current CIH.

June 2023

FCIC-24040

126

Exhibit 51
D.

RMA Regional Office Determined Yield Request (Continued)

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”
2
“AIP Authorized Representative’s Printed Name, Signature and Date”
3
“Agent’s Printed Name, Signature, Code Number and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

127

Exhibit 52

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 yield for the current
crop year. An annual production report is required for all crops with a yield-based plan of insurance that is
required to establish the approved yield. See the CIH for form completion instructions.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8
9
10

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Crop Year”
“Identification Number”
“Identification Number Type”
“Plan of Insurance”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Non-Substantive

Crop Information
Items (7) through (19) are required for the applicable crop year’s production report. These items are
not required for all crop years within the base period unless the insured reports production for
multiple crop years. The AIP-developed form may have single crop year reporting or the AIP may adapt
these standards to allow for multiple crop year reporting, when applicable.
Item
#
1
2
3
4

Element
“Crop”
“Practice/Type/T-yield Map Area/Other Characteristics”
“Unit Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:

5
6
7
8
9
June 2023

_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Other Person(s)”
“Other”
“Record Type”
“Processor Number/Name”
“Number Trees or Vines”
FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
128

Exhibit 52
B.

Production Report (Continued)

Crop Information (Continued)
Item
#
10
11
12
13
14
15

Element
“Insurability”
“FSA Farm/Tract/Field Number”
“Cropland Acres”
“Crop Year of History”
“Total Production”
“Pre-Quality Total Production”

16
17
18

Note: Item is only substantive if the Quality Loss Option is elected.
“Acres”
“Yields”
“Pre-Quality Actual Yield”

19
20

Note: Item is only substantive if the Quality Loss Option is elected.
“Insured Share”
“Multi Crop Year Reporting Reason”

21

Note: Provide instruction for the insured to indication the applicable
reason they are reporting a crop year other than the most
recent APH crop year.
“New Producer
I certify I have not produced the insured crop in the county for more than
two years.”

22
23
24
C.

Note: Non-Substantive if the New Producer Certification Form in
Exhibit 37 is used, (i.e., The Insured (including the SBI) has
produced the crop less than 3 years.) (see the CIH).
“Added Land/New Crop/Practice/Type/TMA”
“State and County”
“Area Classification”

Substantive/
Non-Substantive
Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Non-Substantive
Substantive

Substantive/
Non-Substantive

Substantive
Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

129

Exhibit 52
D.

Production Report (Continued)

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”
2
“Comment”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Non-Substantive

130

Exhibit 53

Actual Production History Database

The production report(s) 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 yield.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Crop Year”
“Identification Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
For items (9) through (16), allow space to provide the appropriate years of the base period.
Item
#
1
2
3
4
5

Element
“Crop”
“Practice/Type/T-yield Map Area/Other Characteristics”
“Unit Number”
“State and County”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:

6
7
8
9
10
11
12

_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Other Person(s) Sharing in the Crop”
“Other”
“T-Yield”
“FSA Farm/Tract/Field Number”
“Crop Year of History”
“Total Production”
“Pre-Quality Total Production”

13
14

Note: Item is only substantive if the Quality Loss Option is elected.
“Acres”
“Yields”

June 2023

FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive
131

Exhibit 53
B.

Actual Production History Database (Continued)

Crop Information (Continued)
Item
#
15 “Pre-Quality Actual Yield”
16
17
18
19
20
21
22
23
24
25

C.

Element

Note: Item is only substantive if the Quality Loss Option is elected.
“Yield Descriptors”
“Total”
“Preliminary Yield”
“Prior Yield”
“Average Yield”
“Adjusted Yield”
“Rate Yield”
“Approved Yield”
“Yield Indicator”
“Required: □ Field Review □ Inspection”

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
Privacy Act Statement
2

Element

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive/
Non-Substantive
Substantive
Substantive

Note: See Para. 503
D.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”

2

June 2023

Note: Substantive if insured elects YE/YC opt out. An insured is only
required to sign the APH database when YE/YC is elected and
the insured has chosen to opt-out of excluding an actual
yield(s) in eligible crop year(s), and/or elected for YC to not
apply to the APH database.
“Comments”

FCIC-24040

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Non-Substantive

132

Exhibit 54

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.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8
9
10

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Crop Year”
Note: First or second year coverage module.
“Identification Number”
“Identification Number Type”
“State and County”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
For items (7) through (12), allow space to provide the appropriate years of the base period. For items
(14) through (18), ensure the rows directly follow the columns from items (7) through (12).
Item
#
1
2
3

Element
“Practice/Type/Map Area/Other Characteristics”
“Unit Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:

4
5
6
7
8
9
10
11
12
June 2023

_____ Other Land Identifier (e.g., Spanish land grants, metes and
bounds, etc.):”
“FSA Farm/Tract/Field Number”
“Other Person(s) Sharing in the Crop”
“T-Revenue”
“Crop Year of History”
“Gross Sales”
“Total Pound Production”
“Acres”
“Yield in Pounds”
“Average Gross Sales per Acre”
FCIC-24040

Substantive
Substantive
Non-Substantive
Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive
133

Exhibit 54
B.

Summary of Revenue History Database (Continued)

Crop Information (Continued)
Item
#
13
14
15
16
17
18
19

C.

Element
“Yield Descriptor”
“Total Number of Years”
“Total Average Gross Sales per Acre”
“Approved Average Revenue per Acre”
“Yield Indicator”
“Required PAIR”
“Comments”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
2

Element
Privacy Act Statement

Substantive/
Non-Substantive
Non-Substantive

Note: See Para. 501
Non-Discrimination Policy Statement

Non-Substantive

Note: See Para. 503

June 2023

FCIC-24040

134

Exhibit 55

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 twoyear coverage module.
A.

Insured Information
Item
#
1
2
3
4
5
6
7
8
9

B.

Element
“Insured’s Name”
“Street and/or Mailing address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Policy Number”
“Crop Year”
“Identification Number”
“Identification Number Type”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Items (7) through (16), are required for the most recent two crop year’s revenue report. These items
are not required for all crop years within the base period unless the insured reports production for
multiple crop years.
Item
#
1
2
3
4

Element
“Practice/Type”
“State and County”
“Unit Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

5
6
7
8
9
10
11
June 2023

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“FSA Farm/Tract/Field Number”
“Other Person(s) Sharing in the Crop”
“Record Type”
“Contract Number”
“Number of Trees”
“Insurability”
“Gross Sales”
FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
135

Exhibit 55
B.

Revenue Report (Continued)

Crop Information (Continued)
Item
#
12
13
14
15
16
17

18
19
C.

Element
“Total Pound Production”
“Acres”
“Yield Descriptor”
“Yield in Pounds”
“Average Gross Sales per Acre”
“Multi Crop Year Reporting Reason”

Substantive/
Non-Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Note: Provide instructions to indicate the applicable reason the
insured is reporting crop years other than the most recent two
crop years in the coverage module.
“Added Acreage”
“Comments”

Substantive
Non-Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
D.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

136

Exhibit 56

Agreement to Combine Optional Units

The Agreement to Combine Optional Units allows a producer to combine multiple optional units into one
optional unit. See also the CIH.
A.

Insured Information
Item #
1
2
3
4
5
6
7
8
9

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City and State”
“Zip Code”
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“State and County”
“Initial Crop Year”
“Policy Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Unit Information
Item #
1
2
3

Element
“Applicable Crops”
“Units Numbers Combined (Identify units by unit number)”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

4
C.

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“FSA Farm/Tract/Field Number”

Substantive

Terms and Conditions
Item #
1

Element
“This is a continuous agreement.”

Substantive/
Non-Substantive
Substantive

(a) “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.”

June 2023

FCIC-24040

137

Exhibit 56
C.

Agreement to Combine Optional Units (Continued)

Terms and Conditions (Continued)
Item #

Element

1
(b) “By signing this Agreement, you agree to farm two or more optional
(Cont.)
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 canceled and continuity of
insurance coverage is broken.”

Substantive/
Non-Substantive
Substantive

(c) “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.”
(d) “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.”
(e) “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.”
(f) “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:
(i) 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

June 2023

FCIC-24040

138

Exhibit 56
C.

Agreement to Combine Optional Units (Continued)

Terms and Conditions (Continued)
Item #
1
(Cont.)

Element
(ii) If any indemnities were paid on the optional units, the approved
yield will be corrected for such crop years as indicated in a.
above and the 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.”

Substantive/
Non-Substantive
Substantive

(g) “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.”
D.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item #
1
2
3

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“AIP Authorized Representative’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

139

Exhibit 57

Producer’s Pre-Acceptance Worksheet

The Producer’s Pre-Acceptance Worksheet applies to Category C Crops; see the CIH for form completion
instructions. Some standards below are crop specific; modify this worksheet in crop information to the
specific Category C Crop.
A.

General Information
Item
#
1
2
3
4
5
6

Element
“Applicant’s/Insured’s Name”
“Applicant’s/Insured’s Policy Number”
“Unit Number”
“Crop”
“State and County”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

7
8
B.

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Crop Year”
“FSA Farm/Tract/Field Number”

Substantive
Substantive

Crop Information
Create a table for the following columns in (1) through (17).
Item
#
1
2
3
4
5
6

7
8

Element
“Block Number”
“Line Number”
“Type”
“Practice”
“Variety”
“Rootstock”
Note: When applicable by crop policy: Arizona-California citrus crop,
grapes, macadamia nuts, peaches, pistachio, plum, prune,
stone fruit, and walnuts.
“Month/Year Planted”
“Month/Year Grafted”

Substantive/
Non-Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
Substantive

Note: Includes dehorned, buckhorned, stumped, etc. as applicable to
crop provision reporting requirements.

June 2023

FCIC-24040

140

Exhibit 57
B.

Producer’s Pre-Acceptance Worksheet (Continued)

Crop Information (Continued)
Item
#
9

Element
“Number of Plants”

10
11
12

Note: Or, “number of trees, vines, bushes.” This item is nonsubstantive for cranberries or lowbush blueberries.
“Plant Spacing”
“Planting Pattern”
“Interplanted with another crop”

13
14

Note: This item is non-substantive for cranberries.
“Acres”
“Density”

15

Note: This item is non-substantive for cranberries or lowbush
blueberries.
“Percent Stand”

16
17

Note: Or “Estimated Percent Plant Cover” for cranberries or lowbush
blueberries.
“Insurable or Uninsurable”
“Totals:”

Substantive/
Non-Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive

Substantive
Substantive

Note: Totals are for Acres and Number of Plants.
C.

Required Questions
Create a block for the following questions, include a Yes □ No □ option at the end of each question
with instruction to check one.
Item
#
1
2

Element
“Has damage (e.g., disease, hail, freeze) occurred to
trees/vines/bushes/bogs that will reduce the insured crop’s production
from previous crop years? If yes to disease, list type.”
“Have practices or production methods (e.g., removal, dehorning,
grafting, transitioning to or from organic) been performed that will
reduce the insured crop’s production from previous crop years?”

Substantive/
Non-Substantive
Substantive
Substantive

(a) “Is acreage transitioning from conventional to organic for the first
year?”
(b) “Is acreage changing from organic to conventional for the first year?”

June 2023

FCIC-24040

141

Exhibit 57
C.

Producer’s Pre-Acceptance Worksheet (Continued)

Required Questions (Continued)
Item
#
3

4
D.

Element
“Organic: has the acreage been affected by a Prohibited Substance
(biological, chemical, or other agent) which results in a change in
practice? If yes, select: □ Organic to Transitional □ Organic to
Conventional”
“Is the current water supply (surface allotment/well) adequate to
produce a normal crop for the crop year being certified above?”

Substantive/
Non-Substantive
Substantive

Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item
Element
#
1
“Applicant’s/Insured’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

142

Exhibit 58

Perennial Crop Pre-Acceptance Inspection Report

The Perennial Crop Pre-Acceptance Inspection Report is to be completed by the AIP. See the CIH for form
completion instructions.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13

Element
“Applicant’s/Insured’s Name”
“Applicant’s/Insured’s Telephone Number”
“Applicant’s/Insured’s Policy Number”
“Applicant’s/Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“Name of Owner”
“Name of Operator”
“Crop”
“Crop Year”
“Unit Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

14
15
B.

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“FSA Farm/Tract/Field Number”
“Location Description”

Substantive
Substantive

Required Questions for Inspector to Complete
Item
#
1
2
3
4

June 2023

Element
“Number of years insured has operated this unit. If less than 3 years,
include previous owner’s name and address, if known.”
“Has this unit been insured in previous years? If yes, include the number
of year’s 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):”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

143

Exhibit 58
B.

Perennial Crop Pre-Acceptance Inspection Report (Continued)

Required Questions for Inspector to Complete (Continued)
Item
#
5
6

7
8
9
10
11
12

Element
“Describe in detail insect control measures used (i.e., integrated pest
management, calendar spray program): Evidence of disease/insects
(check one): □ Rare □ Moderate □ Severe”
“Describe wildlife control measures:”
Note: This item is only substantive when required by the crop
provision reporting requirements.
“Describe in detail the use and placement of bees for pollination. Include
type, quality and location:”
“Describe in detail the varieties being used as pollinizer(s). Include
variety/location, quantity, density and configuration:”
“Is a tree/vine/bush/bog replacement program being carried out?”
“Describe the trellis type and condition:”
“Describe in detail the pruning practices used; date normally completed
and indicate whether pruning is annual or biennial:”
“Describe in detail the irrigation method and source:

Substantive/
Non-Substantive
Substantive
Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Surface: ____ percentage of total supply
Irrigation district name
Allocation last year: ___ percentage of normal
Expected allocation this year: ___ percentage of normal
Irrigation well(s): ___ percentage of normal
How many wells? ____
Total gallons per minute? ___ GPM
Water obtained through water transfer: ___ acre feet per acre
13
14
15
16
17
18

Type of irrigation system”
“Is the unit subject to above normal flood hazards? If so, explain:”
“Describe the type of frost protection used including the average times
used.”
“Are there soil limitations (i.e., slope, depth, drainage, ph., saline/alkali,
toxicity)? If so, explain:”
“What date is/was harvest complete(d) for the unit under normal
conditions?”
“Remarks:”
“Type of mulch used and percent of bare surface covered:”
Note: Item is only substantive for lowbush blueberries.

June 2023

FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive/
Non-Substantive
144

Exhibit 58
B.

Perennial Crop Pre-Acceptance Inspection Report (Continued)

Required Questions for Inspector to Complete (Continued)
Item Element
#
19 “Specific management practices utilized each year of operation on this
bog:”

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Note: Create a table with items (a) and (b) as columns and items (c)
through (j) as rows. This item is only substantive for
cranberries.
(a) “Management Practice”
(b) “Year”
(c) “Fertilization Program”
***
(d) “Sanding Program”
(e) “Insect Program”
(f) “Weed Program”
(g) “Fungicide Program”
(h) “Drainage Program”
(i) “Water Supply”
20

***
21
22

***
23

24

(j) “Method of Harvest”
“Bog manager’s prediction of expected yield of this bog for the next 4
years:”
Note: This item is only substantive for cranberries.
“Describe the use of frost warning system for the bog:”
Note: This item is only substantive for cranberries.
“Describe the presence or absence of a backup power/security system
source for irrigation system and type of system.”

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Note: This item is only substantive for cranberries.
“List by Block: Time needed to flood bog and time needed to remove the
water from the bog.”
Note: This item is only substantive for cranberries.
“Describe the general condition of bog dikes and banks:”
Note: This item is only substantive for cranberries.

June 2023

Substantive/
Non-Substantive

FCIC-24040

Substantive/
Non-Substantive
Substantive/
Non-Substantive
145

Exhibit 58
B.

Perennial Crop Pre-Acceptance Inspection Report (Continued)

Required Questions for Inspector to Complete (Continued)
Item
Element
#
25 “Describe sanding practices used, include the percentage of the bog
sanded last year and the percentage of the bog sanded in the last five
years.”
26

Note: This item is only substantive for cranberries.
“Harvesting Method: Include the method of harvest percentage of wet
and dry last year and the percentage of wet and dry for the next year.”

Substantive/
Non-Substantive
Substantive/
Non-Substantive

Substantive/
Non-Substantive

Note: This item is only substantive for cranberries.
C.

Acreage/Inspection Information
Item
#
1
2
3
4

Element
“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”
“Determine whether current observed conditions reconcile to prior
records”
“Percent Stand”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Note: Create a table with items (a) through (f) as columns and items
(g) through (k) as rows.
(a) “Less than 50%
(b) 50-60%
(c) 61-70%
(d) 71-80%
(e) 81-90%
(f) 91-100%”
(g) “Based on original planting pattern
(h) Spaces occupied by live trees/vines/ bushes/bogs
(i) Bearing trees/vines/ bushes/bogs (percent stand)
(j) Cranberries/lowbush blueberries (estimated percent plant cover)
(k) Insurable Stand”
June 2023

FCIC-24040

146

Exhibit 58
C.

Perennial Crop Pre-Acceptance Inspection Report (Continued)

Acreage/Inspection Information (Continued)
Item
#
5
6
7
8
9
10
11
12
13
14
15
16
17

D.

Element

Substantive/
Non-Substantive
“Describe the previous loss/damage history.”
Substantive
“Determine the current Unit potential (check one): □ Stable □ Declining □
Substantive
Increasing”
“Do trees/vines/bushes/plants have sufficient vigor to produce the
Substantive
Preliminary APH yield computed for this unit? (check one) □ Yes □ No”
“Plant Vigor (check one): □ Good □ Average □ Poor”
Substantive
“Determine if the rootstock variety is adaptable to the area and resistant
Substantive
to disease.”
“If applicable, provide inside bin measurements:”
Substantive
“Insurable acreage and tree/vine/bush/bog information: Verify and/or
Substantive
correct Producer’s Pre-Acceptance Worksheet(s)”
“Uninsurable acreage and tree/vine/bush/bog information: Verify and/or
Substantive
correct Producer’s Pre-Acceptance Worksheet(s).”
“Obtain and attach aerial photo(s)/map(s).”
Substantive
“Additional information and comments (attach additional sheets if
Substantive
necessary):”
“Your evaluation of the management of the operation (check one and
Substantive
explain your choice if below average): □ Above Average □ Average □
Below Average”
“Your evaluation of the orchard/vineyard/bog/grove conditions (check
Substantive
one and explain your choice if below average): □ Above Average □
Average □ Below Average”
“Action Recommended (check one): □ Acceptance □ RMA RO
Substantive
Determined Yield Request □ Rejection”

Required Signatures
Item
#
1
2
3
4

June 2023

Element
“Adjuster Printed Named, Signature and Date”
“Adjuster Telephone Number and Contact Point”
“Supervisor Printed Name, Signature and Date”
“Supervisor Telephone Number”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

147

Exhibit 59

Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet

This worksheet applies to the Dollar Plan for Florida Citrus Fruit (see the CIH).
A.

General Information
Item
#
1
2
3
4
5
6
7

Element
“Applicant’s/Insured’s Name”
“Applicant’s/Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Applicant’s/Insured’s Telephone Number”
“Applicant’s/Insured’s Policy Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

____ Section:
____ Township:
____ Range:

8
9
B.

____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Crop Year”
“State and County”

Substantive
Substantive

Crop Information
Create a table for the following columns in (1) through (17).
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

June 2023

Element
“Block Number”
“Unit Number”
“Crop”
“Date Set Out/Grafted”
“Month/Year Topworked/Buckhorned”
“Type”
“Number of Trees”
“Number of Trees Topworked/Buckhorned”
“Planting Pattern”
“Acres in Block”
“Tree Spacing”
“Percent Stand”
“Number of Trees per Acre”
“Practice”
“Insurable or Uninsurable”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
148

Exhibit 59
B.

Florida Citrus Fruit Producer’s Pre-Acceptance Worksheet (Continued)

Crop Information (Continued)
Item
#
16
17

C.

Element
“Totals:”
Note: Acres in block and number of trees per acre. ***
“Estimated Production Boxes”

Substantive/
Non-Substantive
Substantive
Substantive

Orchard Information
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.
Item
#
1
2
3
4
5
6

D.

Element
“Date of Last Inspection”
“Has the dollar amount of insurance for the insured crop been previously
adjusted due to a reduction of the crop’s production potential?”
“Has an adjustment been applied to the crop’s insurable acres resulting in
a comparable reduction in yield?”
“Has damage (e.g., disease, hail, freeze) occurred to the trees that will
reduce the insured crop’s production?”
“Have cultural practices or production methods (e.g., heavy pruning,
transitioning to organic) been performed that will reduce the insured
crop’s production?”
“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/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
E.

Required Signatures
Item
Element
#
1
“Applicant’s/Insured’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
149

Exhibit 60

Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report

This report is to be completed by the AIP. See the CIH for form completion instructions.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Element
“Applicant’s/Insured’s Name”
“Applicant’s/Insured’s Telephone Number”
“Applicant’s/Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“State and County”
“Policy Number”
“Name of Owner”
“Name of Operator”
“Crop Year”
“Date Set Out/Grafted”
“Month/Year Topworked/Buckhorned”
“Planting Pattern”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:
___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
B.

Individual Citrus Grove Data
Create a table for the following columns in (1) through (12).
Item
#
1
2
3
4
5
6
7
8
9
10

June 2023

Element
“Type”
“Unit Number”
“Block Number”
“Acres in Block”
“Tree Spacing”
“Number of Trees”
“Number of Trees per Acre”
“Tree Age in Years”
“Insurable Condition”
“Estimated Production Boxes”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
150

Exhibit 60
B.

Individual Citrus Grove Data (Continued)
Item
#
11
12
13

14
C.

Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)

Element
“Tree Condition”
“Totals:”
“Excluded Acreage”
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”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Substantive

Other Information
Item
#
1

Element
Create a Block Map (example below).

Substantive/
Non-Substantive
Substantive

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.
Block Map Example:

D.

Required Questions
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.

June 2023

FCIC-24040

151

Exhibit 60
D.

Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)

Required Questions (Continued)
Item
#
1
2
3
4
5
6
7
8

9
10
11

Element
“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:”
“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:”
“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:”
“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:”
“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:”
“Describe weed control measures used for the unit. Include a
description of the orchard 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):
Evidence of disease/insects (check one): □ Rare □ Moderate □ Severe”
“Is a tree replacement program being carried out?”
“If applicable, is fumigation used in the replacement program?”
“Describe in detail the irrigation water source:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Substantive
Substantive
Substantive

Surface: ____ percentage of total supply
Irrigation district name
Allocation last year: ___ percentage of normal
Expected allocation this year: ___ percentage of normal
Irrigation well(s): ___ percentage of normal
How many wells? ____
Total gallons per minute? ___ GPM
12
June 2023

Water obtained through water transfer: ___ acre feet per acre”
“Is the unit subject to above normal flood hazards? If so, explain:”
FCIC-24040

Substantive
152

Exhibit 60
D.

Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)

Required Questions (Continued)
Item
#
13
14

E.

Element
“Are there soil limitations (i.e., slope, depth, drainage, Ph, saline/alkali,
toxicity)? If so, explain:”
“Does producer perform crop protection according to Citrus Health
Management Area (CHMA) guidelines (check one): □ Yes □ No If yes, list
CHMA District.”

Substantive/
Non-Substantive
Substantive
Substantive

Acreage/Inspection Information
Item
#
1
2

Element
“Determine whether current observed conditions reconcile to prior
records”
“Percent Stand by Block”

Substantive/
Non-Substantive
Substantive
Substantive

Note: Create a table with items (a) through (f) as columns and items
(g) through (j) as rows:
(a) “Less than 50%
(b) 50-60%
(c) 61-70%
(d) 71-80%
(e) 81-90%
(f) 91-100%”
(g) “Based on original planting pattern
(h) Spaces occupied by live trees
(i) Bearing trees (percent stand)
3
4
5
6
7
8
June 2023

(j) Insurable Stand”
“Determine the current unit potential (check one): □ Stable □ Declining □
Increasing”
“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? (check one) □ Yes □ No”
“Plant Vigor (check one): □ Good □ Average □ Poor”
“Verify and/or correct Producer’s Pre-Acceptance Worksheet(s).”
“Attach aerial photo(s)/map(s)”
FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
153

Exhibit 60
E.

Florida Citrus Fruit Perennial Crop Pre-Acceptance Inspection Report (Continued)

Acreage/Inspection Information (Continued)
Item
#
9
10
11
12

F.

“Additional information and comments (attach additional sheets if
necessary):”
“Your evaluation of the management of the operation (check one): □
Above Average □ Average □ Below Average”
“Your evaluation of the grove conditions (check one): □ Above Average □
Average □ Below Average”
“Action Recommended (check one): □ Acceptance □ RMA RO
Determined Yield Request □ Rejection”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Required Signatures
Item
#
1
2
3
4
5

G.

Element

Element
“Inspector’s Printed Name, Signature and Date”
“Inspector’s Code Number”
“Date of Inspection”
“Supervisor Printed Name, Signature and Date”
“Supervisor Telephone Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1

Element
Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

154

Exhibit 61

Weighted Average Age/Density Worksheet

See the CIH for form completion instructions.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11

Element
“Applicant’s/Insured’s Name”
“State”
“County”
“Crop”
“Practice”
“Type”
“Variety/Other”
“Crop Year”
“Unit Number”
“Policy Number”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

12
B.

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“FSA Farm/Tract/Field Number”

Substantive

Crop Information
Create a table for the following columns in (1) through (12). Develop a Row for Totals for (6) Density ×
(7) Acres and (3) Set Out Year × (7) Acres.
Item
#
1
2
3
4
5
6
7
8
9
10
11
12

June 2023

Element
“Block”
“Month/Year”
“Set Out Year”
“Acres”
“Set Out Year Extensions”
“Density”
“Acres”
“Density Extensions”
“Totals:”
“Weighted Average Set Out Year”
“Weighted Average Density”
“Transitional Yield”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
155

Exhibit 62
A.

Forage Production Underwriting Report

General Information
Item
#
1
2
3
4
5

B.

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

“Applicant’s/Insured’s Name”
“State”
“County”
“Crop Year”
“Policy Number”

Crop Information
Item
#
1
2
3
4

“Line Number”
“Unit Number”
“FSA Farm/Tract/Field Number”
“Legal Description:
___ Section:
___ Township:
___ Range:

5
6
7
8
9

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Acres”
“Share”
“Shareholder/Farm Name”
“Date Seeded M/D/YY”
“Percentage of Ground Cover”

Substantive
Substantive
Substantive
Substantive
Substantive

(a) “Alfalfa”
(b) “Clover”
10

(c) “Other”
“Forage Stems Per Sq. Ft.”

Substantive/
Non-Substantive

(a) “Alfalfa”
(b) “Clover”
(c) “Other”
Note: Item is only substantive when percent ground cover is 60
percent or more.
June 2023

FCIC-24040

156

Exhibit 62
B.

Forage Production Underwriting Report (Continued)

Crop Information (Continued)
Item
#
11

Element
“Forage Plants per Sq. Ft.”
(a) “Alfalfa”

Substantive/
Non-Substantive
Substantive/
Non-Substantive

(b) “Clover”
(c) “Other”

12
13
14
15
16
C.

Substantive
Substantive
Substantive
Substantive
Substantive

Required Signatures
Item
#
1
2

D.

Note: Item is only substantive when percent ground cover is less
than 60 percent.
“Crop Practice”
“Plants Other than Alfalfa”
“Uninsurable Acres”
“Acres Seeded with Another Crop”
“Remarks:”

Element
“Applicant’s/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

Substantive/
Non-Substantive
Substantive
Substantive

Required Statements
Item
#
1

Element
Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

157

Exhibit 63

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 (see the CIH).
A.

General Information
Item #
1
2
3
4
5

B.

Element
“Agent’s Name”
“AIP Name”
“Seed Company Name”
“Facility/Plant Location”
“Seed Company Representative”

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Create a table with the following items for columns.
Item #
1
2
3
4
5
6
7

C.

Element

“Insured Name”
“State and County of Insured Crop”
“Number of Acres”
“Hybrid Identification”
“Crop”
“Type”
“Practice”

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Signatures
Item #
Element
1
“Agent’s Printed Name, Signature, Code Number and
Date”
2
“AIP Representative’s Printed Name, Signature and Date”

June 2023

FCIC-24040

Substantive/Non-Substantive
Substantive
Substantive

158

Exhibit 64

Irrigated Practice Guidelines

In accordance with the instructions in the CIH, AIPs are to provide a copy of the following Irrigated Practice
Guidelines to all insureds for whom the irrigated practice may apply.
These guidelines are provided to enable insureds to properly report planted or perennial acreage insured
under an irrigated practice consistent with their crop insurance policy. It is 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.
A.

Definitions
The following definitions are provided to facilitate a uniform understanding of the standards and
guidelines for insuring an irrigated practice for planted or perennial crop acreage.
Item #
1

2

Element
Adequacy of Irrigation Facilities: 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.
Efficient Irrigation: Carrying out a good irrigation practice using a
lesser amount of irrigation water than historically applied, but still
achieving the irrigated APH yield by implementing enhanced
management practices to increase efficiency of irrigation water use.

Substantive/
Non-Substantive
Substantive

Substantive

Enhanced management practices to increase efficiency of irrigation
water use include, but are not limited to, the following:
(a) Irrigation Method - Employing an irrigation water distribution
technique or technology that has demonstrated greater efficiency
(e.g., converting gravity flood irrigation to a center pivot or
underground drip tape).
(b) Converting high pressure impact sprinklers to low pressure
impacts under center pivot irrigation.

3

June 2023

(c) Soil Moisture Monitors - Using soil moisture monitor output to set
the schedule and amount of irrigation water applied.
Good Irrigation Practice: The Application of adequate water in an
acceptable manner, at the proper times, to allow production of a
normal crop which is often identified as the approved yield for crops.

FCIC-24040

Substantive

159

Exhibit 64
A.

Irrigated Practice Guidelines (Continued)

Definitions (Continued)
Item #

Element

4

Irrigation Equipment and Facilities: 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:

Substantive/
Non-Substantive
Substantive

(a) are under the control of the insured; or

5

(b) routinely deliver water only to acreage which is owned or
operated by the insured. A center pivot system is considered
irrigation equipment and facilities.
Irrigation Water Supply: The water source and means for supplying
irrigation water, not including equipment or facilities. This includes
the water source and dams, canals, ditches, pipelines, etc., which
contain the water for movement from the water source to the acreage
that:

Substantive

(a) are not under the control of the insured; or

6

7
B.

(b) routinely deliver water to acreage in addition to that which is
owned or operated by the insured.
Reasonable Expectation of Adequate Water: The insured had no
reason to know at the time coverage began the amount of irrigation
water may be limited or reduced. No reasonable expectation exists if
the insured knew, or had reason to know, the amount of irrigation
water may be reduced before coverage begins.
Water Source: The source from which water is made available. This
includes wells, lakes, reservoirs, streams, aquifers, etc.

Substantive

Substantive

Requirements
Item #
1

Element
For planted or perennial acreage to be insured under and irrigated
practice, the insured must:

Substantive/
Non-Substantive
Substantive

(a) be able to document and demonstrate that there is a reasonable
expectation of adequate water (see Subpara. C);
(b) be able to document and demonstrate good irrigation practices;
(c) be able to demonstrate that they have adequate irrigation
equipment and facilities;

June 2023

FCIC-24040

160

Exhibit 64
B.

Irrigated Practice Guidelines (Continued)

Requirements (Continued)
Item #

Element

1
(d) provide verifiable documentation to their AIP by the ARD that the
(Cont.)
irrigation water supply has replenished after a failure of the
irrigation water supply prevented the insured from planting or the
insured had a failure of irrigation water supply; and

Substantive/
Non-Substantive
Substantive

(e) keep separate production records for acreage insured under an
irrigated practice from acreage insured under a practice other than
irrigated (or with no practice applicable) and uninsured acreage.
C.

Determination of Reasonable Expectation of Adequate Water
Item #

Element

1

Factors to be considered (applicable to both the AIP and the insured)
when determining and documenting whether a reasonable expectation
of adequate water existed include, but are not limited to the following:

Substantive/
Non-Substantive
Substantive

(a) Most recent 10-year historical average of available water and any
applicable forecasting data from a credible authority responsible for
monitoring and forecasting such conditions such as Irrigation
Districts, State Department of Water Resources, Bureau of
Reclamation, Water Boards, etc.
Examples: Current Federal, state, or local water district allocations,
historical inflows, current water levels, expected inflows
resulting from snowpack, expected rainfall, etc.;
(b) Water supply availability, quality and usage;
(c) Pump efficiency and capacity;
(d) Water requirements (amount and timing) for all irrigated crops;
(e) Water rights available to the insured (primary, secondary, urban
versus agricultural use, etc.);
(f) Contingency plans to handle water shortages;
(g) Acres to be irrigated;
(h) Ownership of the water source including the legal entitlement or
rights to the water (state or Federal versus landowner or other
private party);

June 2023

FCIC-24040

161

Exhibit 64
C.

Irrigated Practice Guidelines (Continued)

Determination of Reasonable Expectation of Adequate Water (Continued)
Item #

Element

1
(i) Meters, measuring devices and methods used to monitor good
(Cont.)
irrigation practice;

Substantive/
Non-Substantive
Substantive

(j) Soil types, soil moisture levels and pre-plant irrigation needs;
(k) Water conservation methods, devices used and plans utilized (if
applicable);
(l) Past crop planting history and tillage methods;
(m) Supplemental water availability and usage including return flow or
any precipitation which would normally be received, after insurance
attaches;
(n) Recommendations from local Cooperative Extension Service (CES),
National Resource Conservation Service (NRCS), or other source
recognized by CES or NRCS to be an expert in the area regarding
irrigation and crop production;
(o) Decreased water allocation resulting from the diversion of water for
environmental, public use or priority, or other reasons; and
Note:

Not an insurable cause of loss (COL) unless the diversion
is made necessary due to an insured COL.

(p) Management practices used or to be used to carry out efficient
irrigation, as applicable.
D.

Failure to Qualify or Carry Out a Good Irrigation Practice
Item #
1

June 2023

Element
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.”

FCIC-24040

Substantive/
Non-Substantive
Substantive

162

Exhibit 64
D.

Irrigated Practice Guidelines (Continued)

Failure to Qualify or Carry Out a Good Irrigation Practice (Continued)
Item #
2

Element
Failure to carry out a good irrigation practice on acreage properly
insured under the irrigated practice will result in an appraisal for
uninsured causes on such acreage, unless:

Substantive/
Non-Substantive
Substantive

(a) the failure was caused by unavoidable failure of the irrigation water
supply after insurance attached; or
(b) failure or breakdown of the irrigation equipment or facilities due to
an insured COL, provided all reasonable efforts to restore the
irrigation equipment facilities to proper working order within a
reasonable amount of time, unless the AIP determines it is not
practical to do so.
Note:

3

E.

Cost will not be considered when determining whether it
is practical to restore the equipment or facilities.
If a loss is evident, any reported acreage qualifying as an irrigated
practice at the time insurance attaches cannot be revised to a nonirrigated practice after the acreage reporting date, even if liability stays
the same or decreases or if the insured failed to carry out a good
irrigation practice.

Substantive

Prevented Planting Coverage
Item #

Element

1

“Insureds may be eligible for a prevented planting payment for acreage
historically grown under an irrigated practice for which the insured had
no reasonable expectation of adequate water by the final planting date
(or within the late planting period, if applicable). This applies even if the
acreage could have been planted with a non-irrigated practice and the
insured elects not to plant, provided all other prevented planting
provisions have been met, including that an insured COL must have
occurred within the PP insurance period.”
“Insureds must provide, upon the AIP’s request, documentation of the
factors which were considered in reporting that there was no
reasonable expectation of adequate water for the acreage reported as
prevented planting under an irrigated practice.”

2

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

Substantive

163

Exhibit 65
A.

Grass Seed Underwriting Report

General Information
Item #
1
2
3
4
5

B.

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Element

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

“Applicant’s/Insured’s Name”
“State”
“County”
“Crop Year”
“Policy Number”

Crop Information
Item #
1
2
3
4

“Grass Seed Type”
“Unit Number”
“FSA Farm/Tract/Field Number”
“Legal Description:
___ Section:
___ Township:
___ Range:

5
6
7
8
9
10
11
12
13
14
15
C.

___ Other Land Identifier (e.g., Spanish land grants, metes and
bounds, etc.):”
“Acres”
“Share”
“Other Person(s) Sharing in the Crop”
“Date Seeded M/D/YY”
“Area Without Cover or in Other Species”
“Percent Area Without Cover or in Other Species”
“Crop Practice”
“Plants Other than Grass Seed Type”
“Uninsurable Acres”
“Acres Seeded with Another Crop”
“Remarks:”

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Signatures
Item #
1
2

June 2023

Element
“Applicant’s/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

164

Exhibit 65
D.

Grass Seed Underwriting Report (Continued)

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

165

Exhibit 66
A.

Forage Seed Underwriting Report

General Information
Item #
1
2
3
4
5

B.

Element
“Applicant’s/Insured’s Name”
“State and County”
“Agent Information”
“Policy Number”
“Crop Year”

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item #
1
2
3
4

Element

“Unit Number”
“Map Field ID”
“FSA Farm/Tract/Field Number”
“Legal Description:

Substantive/Non-Substantive
Substantive
Substantive
Substantive
Substantive

___ Section:
___ Township:
___ Range:

5
6
7
8
9
10
C.

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Signatures
Item #
1
2

D.

___ Other Land Identifier (e.g., Spanish land grants,
metes and bounds, etc.):”
“Acres”
“Type”
“Date Planted M/D/YY”
“Practice”
“Stand Count per Square Foot”
“Official Use Only”

Element
“Applicant or Self-Certified (Circle One)/Printed Name,
Signature and Date”
“Inspector Printed Name, Signature and Date”

Substantive/Non-Substantive
Substantive
Substantive

Required Statements
Item #
1

Element

Substantive/Non-Substantive
Substantive

Certification Statement

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
June 2023

FCIC-24040

166

Exhibit 67

Sprinkler Irrigated Rice (SIR) Endorsement Application

The SIR Endorsement is continuous but requires an annual application to be completed to certify that all
documentation requirements will be met for each year the SIR Endorsement is in effect.
A.

General Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

B.

Element
“Applicant/Insured’s Name”
“Street Address”
“City”
“State”
“Zip Code”
“Phone Number”
“Cell Phone Number”
“Identification Number”
“Identification Number Type”
“Person Type”
“Spouse’s Name”
“Spouse’s Identification Number”
“Policy Number”
“Agency Name”
“Agency Code”
“Address”
“City”
“State”
“Zip Code”
“Phone Number”
“Applicant/Insured’s Authorized Representative”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Required Certification Statements
Item #
1

Element
“I understand the policy requirements and my responsibilities outlined
in the Sprinkler Irrigated Rice Endorsement and Special Provisions.
Specifically, the required:

Substantive/
Non-Substantive
Substantive

(a) Characteristics for the inbred or hybrid rice to be planted, shall be
an appropriate inbred or hybrid rice variety that is:
(i) adapted for growing conditions found in the southern U.S. rice
growing regions and that is a short to medium season maturity
variety or hybrid. Late season maturity varieties of rice are not
eligible for insurance when sprinkler irrigation is being used;

June 2023

FCIC-24040

167

Exhibit 67
B.

Sprinkler Irrigated Rice (SIR) Endorsement Application (Continued)

Required Certification Statements (Continued)
Item #
1
(Cont.)

Element
(ii) disease resistant to “blast” disease (pyricularia grisea). Varieties
that are moderately resistant, moderately susceptible, or
susceptible to “blast” are not eligible to be insured under this
Endorsement; and

Substantive/
Non-Substantive
Substantive

(iii) a rice variety that has the grain quality potential equal to U.S. No.
1 as established by the USDA Federal Grain Inspection Service.
(b) Equipment to execute a sprinkler irrigation practice:
(i) with the capacity to deliver at least 7.5 gallons of water per
minute per acre; and
(ii) with the ability to complete one complete circle rotation per one
24-hour period and/or with the irrigation system capacity to
ensure appropriate application uniformity over the irrigated
areas in a timely fashion to meet the transpiration needs of rice.
(c) Documentation that verifies:
(i) weekly inspections for nutrients, weeds, insects and disease
along with any action taken;
(ii) fertilizer program executed; and
(iii) irrigation practice, application events and amounts.

2

3

June 2023

(d) Planting Date and Late Planting: Planting dates are established by
State. There is no late planting provision for sprinkler irrigated rice.
Any rice planted under a sprinkler irrigation system after the stated
final planting date is uninsurable.”
“I understand that the company may ask to view all the needed
documentation outlined above to determine the eligibility of insurance.
I understand that I must follow the stated good farming practices
outlined in the Certification Form and the Crop Insurance Handbook. If
the outlined farming practices are not followed or the documentation of
the farming practices are not available for review, I understand that my
insurance coverage may be denied and the crop deemed to be
uninsurable.”
“Remarks”

FCIC-24040

Substantive

Substantive

168

Exhibit 67
C.

Sprinkler Irrigated Rice (SIR) Endorsement Application (Continued)

Good Farming Practice Requirements
Item #

Element

1

“(1) As a producer of sprinkler irrigated rice, you must provide the
company access to the equipment used to plant, care for and
harvest the crop, if requested.”
“(2) Good farming practices are defined; therefore, they must be
documented and available for review by the company at any time to
determine insurability. The practices to be documented are:

2

Substantive/
Non-Substantive
Substantive
Substantive

(a) Weekly inspection for weeds, disease and other problems.
(i) If issues are detected, you must take immediate and
appropriate actions to remedy the issues.
(ii) The actions taken shall be documented (dates and action
taken) with field notes, photographs, etc.
(b) Planting date and conditions. The rice crop is to be planted in:
(i) clean seedbed either by no-till methods or following
conventional tillage.
(ii) Good soil moisture or shall be irrigated immediately after
planting to provide good soil moisture for rice germination.
(c) Planning and implementation of an effective weed control
program.
(i) Dates and actions of the execution of the weed control
program shall be recorded by a third-party agronomy scout
or Certified Crop Advisor. The weed control program should
include documentation of the schedule for herbicide
treatment.
(ii) Fields shall be inspected weekly by a third-party agronomy
scout or Certified Crop Advisor.
(A) Inspection records shall be kept by the third-party
agronomy scout or Certified Crop Advisor.
(B) These records shall be made available to the company for
the purposes of insurance adjustment or audit.
(iii) All herbicides shall be used according to EPA label
requirements and any state and/or local requirements.

June 2023

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169

Exhibit 67
C.

Sprinkler Irrigated Rice (SIR) Endorsement Application (Continued)

Good Farming Practice Requirements (Continued)
Item #

Element

2
(Cont.)

(d) Planning and implementation of an effective pesticide record
keeping program.

Substantive/
Non-Substantive
Substantive

(i) Dates and actions of the execution of the pesticide
application and record keeping program shall be recorded by
a third-party agronomy scout or Certified Crop Advisor.
(A) Fields shall be inspected weekly by a third-party
agronomy scout or Certified Crop Advisor.
(B) Records of inspection must include the recommendation
of pesticide, the date, rate and circumstances of the
application.
(ii) If a commercial applicator applies pesticides to the insured
area, their application records shall be made available for the
purposes of the insurance adjustment or audit.
(iii) All pesticides shall be used according to EPA label
requirements and any state and/or local requirements.
(e) Planning and implementation of a fertilizer and nutrient
management program.
(i) The fertilizer and nutrient management strategy shall be
based on soil testing and targeted yield goals.
(ii) Fertilizer application timing should be determined by crop
condition and growth stage as determined by a third-party
agronomy scout or Certified Crop Advisor.
(A) Weekly inspection records shall document crop growth
stage and crop condition related to fertility.
(B) These records shall be made available to the company, if
requested, for the purposes of insurance adjustment or
audit.
(iii) If a commercial applicator is used for fertilizer application,
their records shall be made available for the purposes of the
insurance adjustment/auditor.
(f) Planning and implementation of a disease control program.

June 2023

FCIC-24040

170

Exhibit 67
C.

Sprinkler Irrigated Rice (SIR) Endorsement Application (Continued)

Good Farming Practice Requirements (Continued)
Item #
2
(Cont.)

Element
(i) Dates and actions of the execution of a disease control
program shall be recorded by a third-party agronomy scout
or Certified Crop Advisor.

Substantive/
Non-Substantive
Substantive

(A) Fields shall be inspected at least weekly by a third-party
agronomy scout or Certified Crop Advisor.
(B) Inspection records shall be kept by a third-party
agronomy scout or Certified Crop Advisor.
(C) These records shall be made available to the company for
the purposes of insurance adjustment or audit.
(ii) If a commercial applicator applies fungicides to the insured
area, their application records shall be made available for the
purposes of the insurance adjustment or audit.
(iii) All fungicides shall be used according to EPA label
requirements and any state and/or local requirements.
(g) Planning and implementation of a water management program
to meet the established evapotranspiration need of rice. You
shall:
(i) Irrigate frequently, with light applications, to maintain
appropriate water content in the effective root zone (i.e., top
6” - 8” of soil profile).
(A) The term “irrigate frequently” means that irrigation shall
occur often enough to provide at least the minimum
amount of water needed for normal growth; to include
an accounting for rainfall and irrigation events so that soil
water conditions in the effective root zone does not
cause crop water stress on the rice being grown.
(B) In the event of a loss, the Company may use the irrigation
logs, rainfall reports and information from county
extension offices or other third-party agricultural services
to determine if the level of irrigation is sufficient to be
considered a “good farming practice.”

June 2023

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171

Exhibit 67
C.

Sprinkler Irrigated Rice (SIR) Endorsement Application (Continued)

Good Farming Practice Requirements (Continued)
Item #
2
(Cont.)

Element
(ii) Document irrigation applications. This documentation may
be documented by a third-party agronomy scout, Certified
Crop Advisor, or by digital means, such as flow meters or
digital control panels purchased from the sprinkler
equipment manufacturer.

Substantive/
Non-Substantive
Substantive

(A) Documentation shall include: irrigation dates, irrigation
depth applied for each application and rainfall dates and
amounts from planting to maturity; to include field notes
for any irrigation event that did not irrigate the entire
field.
(B) Documentation shall include: documentation of
equipment inspection and water recommendations as
recorded by a third-party agronomy scout or Certified
Crop Advisor. For center pivot irrigation management,
you should seek to keep the wheel tracks as dry as
possible to minimize tire ruts and prevent the machine
from getting stuck so that the proper application and
timing are maintained during the growing season.
(C) Your irrigation management practice should prevent
irrigation runoff.”
D.

Required Signatures
Item #
1
2

E.

Element
“Applicant/Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature and Date”

Substantive/
Non-Substantive
Substantive
Substantive

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
June 2023

FCIC-24040

172

Exhibit 68

Florida Fruit Tree Producer’s Pre-Acceptance Worksheet

The Florida Fruit Tree Producer’s Pre-Acceptance Worksheet applies to the Dollar Plan for Florida Fruit Tree
(see the CIH).
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12

B.

Element
“Applicant’s/Insured’s Name”
“Applicant’s Insured’s Street and/or Mailing address”
“City and State”
“Zip Code”
“Applicant’s/Insured’s Telephone Number”
“Applicant’s/Insured’s Policy Number”
“Crop Year”
“County”
“Agency Name”
“Agency Street and/or Mailing Address”
“Agency City and State”
“Agency Zip Code”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Create a table that includes the following columns (1) through (15).
Item
#
1
“Legal Description:

Element

Substantive/
Non-Substantive
Substantive

___ Section:
___ Township:
___ Range:

2
3
4
5
6
7
8
9
10
11
12
13
June 2023

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Unit Number”
“Block Number”
“Crop”
“Type”
“Date Set Out/Grafted”
“Tree Age”
“Trees per Acre”
“Acres in Block”
“Tree Spacing”
“Tree Count”
“Tree Stage”
“Number of Trees”
FCIC-24040

Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
173

Exhibit 68
B.

Florida Fruit Tree Producer’s Pre-Acceptance Worksheet (Continued)

Crop Information (Continued)
Item
#
14 “Percent of Trees”
15 “Stage Block Number”

C.

Element

Substantive/
Non-Substantive
Substantive
Substantive

Other Information
Item
Element
#
1
Create a grove location plat map to attach to the worksheet. The Insured
or 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. See
example after Item 2.
2
“Remarks”

Substantive/
Non-Substantive
Substantive

Substantive

Note: Enter notes pertinent to the grove certification. Once the
initial certification (worksheet and grove location plat map)
has been provided, carryover insureds should self-certify in
the remarks section of the original PAW that “No change for
XXXX CY” has occurred with initials and date. If changes occur
in any CY that alter the stage the stage-block designations or
the number of trees in each stage block, the insured should
note the revisions and their date in the remarks section.
Example:

June 2023

Section: Grove 1

FCIC-24040

174

Exhibit 68
D.

Florida Fruit Tree Producer’s Pre-Acceptance Worksheet (Continued)

Required Signatures
Item
#
1
2
3
4

E.

Element
“Applicant’s/Insured’s Printed Name, Signature and Date”
“Inspector’s Printed Name, Signature and Date”
“Inspector’s Code Number”
“Date of Inspection”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

175

Exhibit 69

Marketing Certification

The Marketing Certification is required annually and must be completed by insureds that intend to direct
market any portion of their crop or when acceptable verifiable production records are required, but these
records do not exist because records are controlled by the insured or are not from a disinterested third party,
because they, or a person related to them, generates the supporting records (e.g., vertically integrated). See
the CIH for further completion and certification instructions.
A.

General Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

B.

Element
“Insured’s Name”
“Street and/or Mailing Address”
“City”
“State”
“Zip Code”
“Insured’s Telephone Number”
“Crop Year”
“Policy Number”
“State”
“County”
“Identification Number”
“Identification Number Type”
“Agency Name”
“Agency Code”
“Agent Name”
“Agent Street and/or Mailing Address”
“Agent City”
“Agent State”
“Agent Zip Code”
“Agent Telephone Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item #
1
2
3
4
5
6

June 2023

Element
“Crop”
“State and County”
“Plan of Insurance”
“Type”
“Practice”
“Unit Number”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

176

Exhibit 69
B.

Marketing Certification (Continued)

Crop Information (Continued)
Item #
7

Element
“Legal Description:

Substantive/
Non-Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:

8
9
10
11
C.

_____ Other Land Identifier (e.g., Spanish land grants, metes and
bounds, etc.):”
“FSA Farm, Tract, Field Number”
“Field Location Name”
“Expected Harvest Date”
“Remarks”

Substantive
Non-Substantive
Substantive
Substantive

Definitions
Item #

Element

1

“Direct Marketing - The sale of the insured crop directly to consumers
without the intervention of an intermediary such as a wholesaler,
retailer, packer, processor, shipper, buyer, or broker. Production
records are controlled exclusively by the policyholder. Examples of
direct marketing include selling through an on-farm or roadside stand, a
farmer's market, or permitting the general public to enter the acreage
for the purpose of harvesting or picking all or a portion of the crop.
Only the portion of the crop sold directly to consumers will be
considered direct marketed.”
“Disinterested Third Party - A person that does not have any familial
relationship (parents, brothers, sisters, children, spouse, grandchildren,
aunts, uncles, nieces, nephews, first cousins, or grandparents, related by
blood, adoption or marriage, are considered to have a familial
relationship) with you or who will not benefit financially from the sale of
the insured crop. Persons who are authorized to conduct quality
analysis in accordance with the Crop Provisions are considered
disinterested third parties unless there is a familial relationship.”
“Production Record - A written record that documents your actual
production reported on the production report. The record must be an
acceptable verifiable record or an acceptable farm management record
as authorized by FCIC procedures.”

2

3

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive

Substantive

Substantive

177

Exhibit 69
C.

D.

Marketing Certification (Continued)

Definitions (Continued)
Item #

Element

4

“Verifiable Record - A contemporaneous record from a disinterested
third party that substantiates your actual production reported on the
production report. The record must be a document or evidence from a
disinterested third party that is accurate and can be validated or
verified.”

Substantive/
Non-Substantive
Substantive

General Information Regarding Records
Item #

Element

1

“The types of records listed below may be considered acceptable
production records. Acceptable records may vary by crop policy.
Discuss your crop’s acceptable record requirements with your insurance
provider prior to reporting your production report for the applicable
crop year. Generally, disinterested third-party records are required to
verify information reported by you on the production report; however,
completion of this form when records do not exist from a disinterested
third party, allows you to provide acceptable records that are not from a
disinterested third party.”
“In addition to the requirements provided by each type of acceptable
production record, acceptable production records must:

2

Substantive/
Non-Substantive
Substantive

Substantive

(a) Be legible.
(b) Support your production report in accordance with your crop policy
(e.g., by unit, practice, type, other characteristics, or other reporting
requirements applicable).
(c) Contain production for the applicable crop year being reported by
you.
(d) Be in the applicable unit of measure for production (e.g., bins, bags,
lugs, etc.) in accordance with your crop policy.
(e) Not be production summaries or estimates of production, or
summaries or totals that do not identify crop and/or quantity by
crop (e.g., hourly pick records, cash boxes, etc.) unless allowed by
the crop policy.”

June 2023

FCIC-24040

178

Exhibit 69
D.

Marketing Certification (Continued)

General Information Regarding Records (Continued)
Item #
3

E.

Element
“We may also request additional records or information to verify your
production report. For example, you may be requested to provide a
statement of your internal control procedures and processes. The
statement must substantiate how your policy’s production is kept
separate from the production of other producers whose crop(s) are
handled or marketed through the same operation, packing or
processing facility or marketing channel.”

Substantive/
Non-Substantive
Substantive

Acceptable Production Records (acceptability depends upon crop policy, discuss with your insurance
provider)
Item #
1

Element
“Production Commercially Sold or Stored:

Substantive/
Non-Substantive
Substantive

The following records, or similar records, are acceptable:
(a) Gin Records;
(b) Ledger Sheets;
(c) Load Summaries;
(d) Marketing Outlet Records;
(e) Processor Records;
(f) Buyer Records;
(g) Distiller Records;
(h) First Handler Records;
(i) Warehouse Receipts;
(j) Elevator Receipts;
(k) Settlement Sheets;
(l) Storage Facility Records;
(m) Packer Records;
(n) Broker Records; or
(o) Boiler House Records.”
June 2023

FCIC-24040

179

Exhibit 69
E.

Marketing Certification (Continued)

Acceptable Production Records (acceptability depends upon crop policy, discuss with… (Continued)
Item #
2

Element
“The following items must be contained on each acceptable record.
Please note that if items (a) through (i) are not provided on the
acceptable record, the insured must annotate this information on the
record or provide this information separately:

Substantive/
Non-Substantive
Substantive

(a) crop;
(b) quantity of production that can be converted to the proper unit of
measure, if necessary;
(c) name of insured;
(d) date of transaction;
(e) name of warehouse, elevator, marketing outlet, storage facility,
processor, packer, buyer, broker, distiller, boiler house or first
handler, etc., as applicable;
(f) the unit number, block number, or location of the production;
(g) practice, type or other information as required by your crop policy;
(h) crop year commodity was produced; and

3

(i) planting period from which production was produced, if actuarial
documents designate separate planting periods for the crop.”
“Pick Records (Piece Rate):

Substantive

(a) Must include all of the following to be acceptable.
(i) The name of the person(s) paid by you for the harvest of the
crop;
(ii) The applicable type, practice or other information required by
your policy for the applicable crop year;
(iii) The pick date and location of the crop; and
(iv) The price paid per volume and the price paid must be on the
basis of the insurable unit of measure and weight. When
applicable, the volumes of the field containers must be provided
(e.g., bins) and any applicable volume/weight of the pieces
picked;

June 2023

FCIC-24040

180

Exhibit 69
E.

Marketing Certification (Continued)

Acceptable Production Records (acceptability depends upon crop policy, discuss with… (Continued)
Item #

Element

3
(b) If requested, verifiable proof of payment to the picker(s) for the
(Cont.)
harvesting of the crop must be provided. Supporting records may
include:

Substantive/
Non-Substantive
Substantive

(i) Copy of canceled check(s) to picker with the bank’s stamp of
payment.
(ii) Copy of payments made to Social Security Administration for tax
payments made on behalf of picker(s).
(iii) Other proof of payment to the picker, (e.g., paid invoice, other
bank certification of payment).

4

(iv) Copies of all pick records for the applicable crop year. When
applicable, the copies must be of the actual daily running tallies
of production harvested by each picker and location.”
“Machine Harvest Records:

Substantive

Must include all of the following to be acceptable:
(a) The insured’s name;
(b) The name of the crop;
(c) The date of harvest;
(d) The unit number or the location of the production;
(e) Crop year;
(f) The practice, type, or other information in accordance with your
crop policy; and
5

(g) The quantity of weighed production.”
“Certified Scale Weight Records:

Substantive

Must include all of the following to be acceptable:
(a) The insured’s name;
(b) The name of the crop;
(c) The date of harvest;

June 2023

FCIC-24040

181

Exhibit 69
E.

Marketing Certification (Continued)

Acceptable Production Records (acceptability depends upon crop policy, discuss with… (Continued)
Item #

Element

5
(d) The unit number or the location of the production;
(Cont.)
(e) Crop year;

Substantive/
Non-Substantive

(f) The practice, type, or other information in accordance with your
crop policy; and
(g) The quantity/weighed production.”
6

“Sales Records (Direct Marketing):

Substantive

Must include the following to be acceptable:
(a) Contemporaneous daily sales register:
(i) The records must specify or be supported by receipts that
specify, the crop, quantity/weight sold, grade (when available to
the insured) and amount received; and
(ii) If requested, these records must be supported by tax forms or
other receipts verifying income from the sale of the crop; or
(b) Transaction Summary:
In lieu of daily sales records, you may provide a transaction summary
of sales (seasonal or annual) for the applicable crop year being
reported from an electronic point of sale system. Transaction
summary of sales records must be contemporaneous and meet all
the following to be acceptable:
(i) The records must specify the crop, quantity/weight sold, grade
(when available to the insured) and amount received through
credit card or cash transactions for the identified crop;
(ii) Must provide a legend when codes are used to differentiate
insured crops from other items sold through the point of sale
system;
(iii) A Summary sheet of sales (seasonal or annual) must only be
reported for the applicable crop year; and
(iv) If requested, these records must be supported by tax forms or
other receipts verifying income from the sale of the crop. When
the summary of sales does not match the tax forms, your
insurance provider may request a breakdown of daily sales.”
June 2023

FCIC-24040

182

Exhibit 69
E.

Marketing Certification (Continued)

Acceptable Production Records (acceptability depends upon crop policy, discuss with… (Continued)
Item #
7

Element
“FSA or CCC Verified Documents:

Substantive/
Non-Substantive
Substantive

Document must provide evidence of production that was determined
and verified by an authorized representative of FSA or CCC. This does
not include insured’s certifications of production or estimates of
production. The FSA or CCC must have verified the existence of the
production.”
F.

The following allowable records, or other records not specified, may be used in conjunction with
your acceptable production records to substantiate your production report:
Item #
1

Element
“Pre-harvest Appraisal:

Substantive/
Non-Substantive
Substantive

(a) Is an appraisal conducted by an AIP to determine potential
production for acreage that has not been harvested on the unit, or
policy, as applicable.
(b) Will be used in conjunction with your own acceptable production
records.
(c) May be requested by you on this form if:
(i) You direct market your crop, have acceptable production records
and you need a pre-harvest appraisal to assist in production
reporting by allocating your acceptable production records to
the applicable actual production history (APH) database.
(ii) You do not market to a disinterested third party and your
insurance provider determines intermediary records do not
contain all information required by the applicable crop policy for
production reporting.
(d) Your policy may require an appraisal and you must notify your
insurance provider, in accordance with your policy.
(e) Your insurance provider may elect to conduct an appraisal, when
applicable, (e.g., unharvested acreage).”

June 2023

FCIC-24040

183

Exhibit 69
F.

Marketing Certification (Continued)

The following allowable records, or other records not specified, may be used in…(Continued)
Item # Element
2

Substantive/
Non-Substantive
Substantive

“Tax Records:
Tax records alone are not considered acceptable production records
because they are not generally on the same basis as the information
required on a production report. However, your insurance provider or
USDA may use tax records in combination with other records for
verification, for example to identify income and production derived
from the sale or verification of payments made to pickers when pick
records are provided.”

G.

Required Statements
For items (1) through (4), form completion procedures must provide instructions to check boxes when
appropriate.
Item #

Element

1

“I certify that I intend to direct market my crop and will have production
records that meet the criteria above, separated by the applicable
insurable APH database.”
“I certify that I intend to direct market my crop and will have production
records that meet the criteria above; however, my records will not be
available by the applicable insurable APH database. I request a preharvest appraisal to use in conjunction with my acceptable production
records to allocate my production by APH database and I will notify my
insurance provider at least 15 days prior to harvest.”
“I certify some or all of the production records will be from an
intermediary (e.g., wholesaler, retailer, packer, processor, shipper,
buyer, or broker) controlled by me or a non-disinterested third party
and I will have production records that meet the criteria above.”
“I certify some or all of the production records will be from an
intermediary (e.g., wholesaler, retailer, packer, processor, shipper,
buyer, or broker) controlled by me or a non-disinterested third party
and my records will not meet the criteria above. I request a pre-harvest
appraisal to use in conjunction with my intermediary production records
to facilitate production reporting by APH database and I will notify my
insurance provider at least 15 days prior to harvest. I understand that
my insurance provider must approve this request.”

2

3

4

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

Substantive

Substantive

184

Exhibit 69
G.

Marketing Certification (Continued)

Required Statements (Continued)
Item #

Element

5

7

“If I fail to timely provide the required notification, and do not have
acceptable production records, it may result in assigned yields in
accordance with section 3(g) of the Common Crop Insurance Policy
Basic Provisions (7 CFR § 457.8) or indemnity reductions in accordance
with my policy.”
“I understand this notification will not fulfill my requirement to provide
a notice of loss in case of crop damage.”
Certification Statement

8

Note: See Para. 502
Privacy Act Statement

Substantive

9

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

6

Substantive/
Non-Substantive
Substantive

Substantive
Substantive

Note: See Para. 503
H.

Required Signatures
Item #
1
2
3

Element
“Insured’s Printed Name, Signature and Date”
“Agent’s Printed Name, Signature, Date and Code Number”
“AIP Authorized Representative’s Name, Signature and Date”
Note: Substantive when item G(4) is requested.

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive/
Non-Substantive

185

Exhibits 70-80 (Reserved)

June 2023

FCIC-24040

186

Section 5: Loss Adjustment Forms
Certification Form

Exhibit 81

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.
A.

General Information
Item
#
1

Element
The following statement must appear below the form title:

Substantive/
Non-Substantive
Substantive

“Complete and mail this form within (5) days (or within the timeframe
specified by your Approved Insurance Provider) after:
(a) all acreage in the unit has been put to another use,
(b) completion of replanting on the unit for replanting payment,
(c) For nursery, all Zero Market Value (ZMV) plants on the unit have been
destroyed, or
2
3
4
5
B.

Substantive
Substantive
Substantive
Substantive

Crop Information
Item
#
1
2
3
4
5

C.

(d) any action to which you have certified as stated on this form.”
“Insured’s Name”
“Policy Number”
“Date Originate”
“Return to: (include Adjuster’s Name, AIP Name, Mailing Address, City,
State, Zip Code)”

Element
“Crop Year”
“Crop”
“FSA Farm/Tract/Field Number”
“Unit Number”
“Unit Acres”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Replant/Other Uses of Acreage Information
Item
#
1

Element
Add this statement above the table.

Substantive/
Non-Substantive
Substantive

“Replant, destruction, or other use of acreage (plants for nursery)
identified was completed on the date(s) shown.”
June 2023

FCIC-24040

187

Exhibit 81
C.

Loss Adjustment Certification Form (Continued)

Replant/Other Uses of Acreage Information (Continued)
Item
#
2

Element
Create a table with the following columns in the exact order listed below
from left to right.

Substantive/
Non-Substantive
Substantive

(a) “Field Identification Symbol (Plant Location for Nursery)”
(b) “Intended Use”
(c) “Acres (Number of Plants for Nursery)”
(d) “Actual Use”
(e) “Acres (Number of Plants for Nursery)”
(f) “Date”
(g) “Replant Cost per Acre”
3

(h) “Practice/Type or Class”
Create one row for the following:

Substantive

4

“Totals”
Allow additional space for, or provide a separate form for:

Substantive

5

“Remarks:”
Insert the following footnote.

Substantive

“Refer to the crop policy qualifications for replanting payments.”
Example Table for C:
“Replant, destruction, or other use of acreage (plants for nursery) identified was completed on the
date(s) shown.”
Field Identification
Symbol (Plant
Location for Nursery)

Intended
Use

Acres
(Number of
Plants for
Nursery)

Actual
Use

Acres
(Number of
Plants for
Nursery)

Date

Replant
Cost per
Acre

Practice/Type
or Class

Totals
*Refer to the crop policy qualifications for replanting payments.

Remarks:

June 2023

FCIC-24040

188

Exhibit 81
D.

Loss Adjustment Certification Form (Continued)

Required Loss Adjustment Statements
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.
Item
Element
#
1
“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.”
2
“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.”
3
“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.”

E.

Substantive/
Non-Substantive
Substantive

Substantive

Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

189

Exhibit 81
E.

Loss Adjustment Certification Form (Continued)

Required Statements (Continued)
Item
Element
#
4
Include this statement above the insured’s signature.

Substantive/
Non-Substantive
Substantive

“I understand that the information on this form may be used for
processing the claim which I previously signed.”
F.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”
2
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”

G.

Substantive/
Non-Substantive
Substantive
Substantive

Other Information
Item
#
1

June 2023

Element
Include the following checklist and title “For Office Use Only.” This check
list should appear next to the Loss Adjuster’s Signature.
□

“Accepted”

□

“Rejected”

□

“Second Inspection”

FCIC-24040

Substantive/
Non-Substantive
Substantive

190

Exhibit 82

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 100 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.
A.

General Information
Item #
1

Element
The following statement must appear below the form title:

Substantive/
Non-Substantive
Substantive

“The Self-Certification Replant Worksheet may be used when the
acreage to be replanted is 100 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.

2
3
4
B.

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).”
“Insured’s Name”
“Policy Number”
“Claim Number”

Substantive
Substantive
Substantive

Crop Claim Information
Item #
1
2
3
4
5
6
7

June 2023

Element
“Crop Year”
“Crop”
“Share”
“Unit Number”
“FSA Farm/Tract/Field Number”
“Unit Acres”
“Replanted Acres”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

191

Exhibit 82
B.

Loss Adjustment Self-Certification Replant Worksheet (Continued)

Crop Claim Information (Continued)
Item #
8

Element
“Legal Description:

Substantive/
Non-Substantive
Substantive

___ Section:
___ Township:
___ Range:

9
10
11
12
13

14

___ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Cause of Damage”
“Date of Damage”
“Original Plant Date”
“Replant Date”
“Field Diagram”

Substantive
Substantive
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. Add the instruction in item (14) to the field diagram.
“Draw the field where the crop is planted. Shade the area actually
replanted.”

Substantive/
Non-Substantive

Example: (example is non-substantive)

15

“Indicate the practice/type utilized”

Substantive

Note: Provide a checklist with two columns titled “Original” and
“Replanted” of the following practice/types:
(a) “Drilled”
June 2023

FCIC-24040

192

Exhibit 82
B.

Loss Adjustment Self-Certification Replant Worksheet (Continued)

Crop Claim Information (Continued)
Item #

Element

15
(b) “Broadcast”
(Cont.)
(c) “Airplane-seeded”

Substantive/
Non-Substantive
Substantive

(d) “Rowed”
(e) “Dry Bean Type”
(f) “Tillage Method”
Note: Provide instruction to write-in tillage method used for
original and replant acreage.
(g) “Other”
16

Note: Provide instruction to write in a practice/type if not listed.
“My yield potential for acres to be replanted is _____ per acre.”

Substantive

17

Note: Provide instruction to answer the question.
“Is damage on your farm similar to other farms in the area? Yes □ No □”

Substantive

18

Note: Provide instruction to answer the question.
“The following represents my actual replant costs as:

Substantive

_____ Landlord
_____ Tenant
_____ Owner/Operator”
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.
C.

Other Information
Provide instruction for the reviewer to check when attached or accompanies the Self-Certification
Replant Worksheet.
Item #
1
2
3

June 2023

Element
“Special Report”
“Reviewer’s Remarks”
“Reviewer Code and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

193

Exhibit 82
C.

Loss Adjustment Self-Certification Replant Worksheet (Continued)

Other Information (Continued)
Item #

Element

Substantive/
Non-Substantive
Substantive

4

“Actual/Replant Acres”

5

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.
“Date of Damage”

Substantive

6

Note: Provide instruction for the reviewer to enter “O.K” if the
reviewer verifies the date of damage agrees with the date
entered above.
“Cause of Damage”

Substantive

7
8
9

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.
“Replant Practice”
“Did the acreage appear to qualify? Yes □ No □”
“Actual Cost”

Substantive
Substantive
Substantive

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.
D.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503

June 2023

FCIC-24040

194

Exhibit 82
D.

Loss Adjustment Self-Certification Replant Worksheet (Continued)

Required Statements (Continued)
Item # Element
4

Include this statement above the insured’s signature.

Substantive/
Non-Substantive
Substantive

“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 supporting papers are subject to
audit and approval by the insurance provider and that my signature
herein authorizes the insurance provider to process a replanting
payment in accordance with the terms of my insurance contract.”
E.

Required Signatures
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

195

Exhibit 83

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 has been modified to fit their region and the crops insured. See the LAM for more information
and completion instructions regarding this form.
A.

General Information
Item
#
1
2
3
4

B.

Element
“Insured’s Name”
“Policy Number”
“Claim Number”
“Crop(s) - Units”

Substantive/
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive

Claim Information
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.
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

June 2023

Element
“Insured Present”
“Insurable Entity Verified”
“Timely Notice”
“Share Verified”
“Companion Contract Verified (if applicable)”
“Legal Description Verified”
“Practice(s) Insurability Verified”
“Insurable Type/Variety Verified”
“Unit/Unit Division Verified”
“Planting Dates Verified”
“Risk Area Verified”
“Insurable Causes of Loss”
“Similar Damage”
“Reasonable APH”
“Insurable Acreage”
“Sharing Interests”
“Options/Endorsements”
“Review Previous Report”
“Previous Appraisals”
“Quality Adjustment Eligibility Verified”
“Acreage Determined/Method”
“Acreage Replanted”
“Replanting Payment”
“Certification Form”
“Sold Production Verified”
FCIC-24040

Substantive/
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
196

Exhibit 83
B.

Claim Information (Continued)
Item
#
26
27
28
29
30
31
32
33
34
35
36

C.

Loss Adjustment Claim Checklist (Continued)

Element
“Farm-Stored Production Verified”
“Commingled Production”
“Fed Production Verified”
“Other Names/Entities for Production Verified”
“All Production Accounted For”
“Unusual/Controversial Circumstances”
“Reviewed Completed Claim with Insured or Insured’s Representative”
“Obtained Signatures”
“Second Crop Acreage”
“Signatures”
“Other”

Substantive/
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive
Non-Substantive

Required Signatures
Item
#
1

Element
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”

Substantive/
Non-Substantive
Non-Substantive

Note: Obtaining a signature is optional unless otherwise instructed
by the AIP; however, it is recommended that adjusters sign
the form to facilitate necessary follow-up actions.

June 2023

FCIC-24040

197

Exhibit 84

Loss Adjustment Simplified Claims Qualification Process and Notice of Loss

AIP and insured participation in SCP are 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
authorized crops and other information pertaining to SCP criteria, see also LAM Exhibit 17.
A.

General Information
Item #
1
2
3
4
5
6
7
8
9
10
11
12
13

Element
“Insured’s Name”
“Policy Number”
“Agent Name”
“Insured’s Telephone Number”
“Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Crop (only one per form)”
“Crop Year”
“County Where Crop Is Grown (only one per form)”
“Non-Loss (N-L) Units and Establish Production Per Acre”
“Loss Unit Number”
“Cause of Loss”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

(a) “Primary Cause/Percentage”
14

(b) “Secondary Cause/Percentage”
“Date of Damage”

Substantive

(a) “Primary Cause Date of Damage”
15
16
17
18
B.

(b) “Secondary Cause Date of Damage”
“Harvest Completion Date”
“Companion Contract Yes □ No □”
“Assignment of Indemnity Yes □ No □”
“Transfer of Right to an Indemnity Yes □ No □”

Substantive
Substantive
Substantive
Substantive

Loss Information
Create a checklist with the following questions and instruct to answer Yes □ No □, allow additional
space for explanation where applicable. All questions are substantive.
Item #
1

June 2023

Element
“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.”
FCIC-24040

Substantive/
Non-Substantive
Substantive

198

Exhibit 84
B.

Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)

Loss Information (Continued)
Item #

Element

2

“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.”
“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.”
“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?”
“Has any production from any acreage from the units listed in [insert
location on the form the loss unit number information is referenced]
been farm stored, fed to livestock, or saved for seed? If Yes, list the unit
number(s) for which “Yes” applies.”
“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).”
“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.”
“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:

3

4
5

6

7

8
9
10

Substantive/
Non-Substantive
Substantive

Substantive

Substantive
Substantive

Substantive

Substantive

Substantive
Substantive
Substantive

(a) Your share? If no, list the unit(s) and explain:
(b) The legal description(s) and/or FSA farm 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,
June 2023

FCIC-24040

199

Exhibit 84
B.

Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)

Loss Information (Continued)
Item #

Element

10
(d) The type or variety (if applicable)? If no, list the unit(s) for which
(Cont.)
“No” applies and enter the correct type or variety for each unit
listed.

Substantive/
Non-Substantive
Substantive

(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.”
C.

Required Statements
Item #

Element

1

Certification Statement

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

4

Note: See Para. 503
Simplified Claims Qualification Process Statement

Substantive

“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.

June 2023

FCIC-24040

200

Exhibit 84
C.

Loss Adjustment Simplified Claims Qualification Process and Notice of Loss (Continued)

Required Statements (Continued)
Item #

Element

4
Once this completed Notice of Loss form and supporting documentation
(Cont.) 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/
Non-Substantive
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 unit 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 are allowed 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.”
D.

Required Signatures
Item #
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date”
“AIP Verifier’s Printed Name, Signature, Code Number and Date”
FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
201

Exhibit 85

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.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13

B.

Element
“Insured’s Name”
“Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Best Time to Contact: [INSERT TIME] AM/PM”
“Policy Number”
“Claim Number”
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code’
“Agent’s Telephone Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Non-Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item
#
1
2
3
4
5

Element
“Crop Year”
“Crop”
“Unit Number”
“Acres”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Non-Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:
_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”

6
7
8
9
June 2023

Note: See associated required statement in item D(4) below. This
statement is Substantive when this item appears on the form.
“Date of Damage”
“Cause of Damage”
“Estimated Production”
“Expected Harvest Date”
FCIC-24040

Substantive
Substantive
Non-Substantive
Non-Substantive
202

Exhibit 85
C.

Loss Adjustment Notice of Damage or Loss (Continued)

Notice Information
Item
Element
#
1
Include the following instruction:

2

“Refer to the applicable Basic Provision or Crop Provisions for more
information regarding damage or loss notice reporting requirements.”
“This is a notice of:

Substantive/
Non-Substantive
Non-Substantive

Substantive

□ Damage Only: At this time, it appears that the damage will exceed the
guarantee.
□ Probable Loss.

3
4

□ 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.”
“Insured Intends to: (Check One)

Substantive
Substantive

□ Harvest
□ To Chop/Silage
□ Leave for Cover
□ Destroy
□ Plant to Another Crop
□ Pasture
□ Hay
□ Direct Market Crop
□ Replant
□ Unknown
5

June 2023

□ Other, Explain in the comments section”
“If the Insured intends to replant and a replanting payment is applicable,
is the acreage greater than 100 acres of the unit? Yes □ No □ (Check
One)”

FCIC-24040

Substantive

203

Exhibit 85
C.

Loss Adjustment Notice of Damage or Loss (Continued)

Notice Information (Continued)
Item
Element
#
6
“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)”

D.

Substantive/
Non-Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

4

5

Note: See Para. 503
“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.
“I am an agent, employee, or contractor affiliated with the Federal crop
insurance program □ Yes □ No (Check One)”

Substantive

Substantive

Note: Include instruction for insured to complete.
E.

Required Signatures
Item
#
1
2

June 2023

Element
“Insured’s Printed Name, Signature and Date of Notice”
“Agent’s Printed Name, Signature, Code Number and Date”

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

204

Exhibit 86

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.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12
13

B.

Element
“Insured’s Name”
“Insured’s Street and/or Mailing Address”
“City and State”
“Zip Code”
“Insured’s Telephone Number”
“Best Time to Contact: [INSERT TIME] AM/PM”
“Policy Number”
“Claim Number”
“Agent’s Name”
“Agent’s Street and/or Mailing Address”
“Agent’s City and State”
“Agent’s Zip Code”
“Agent’s Telephone Number”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Non-Substantive
Substantive
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Crop Information
Item
#
1
2
3
4
5

Element
“Crop Year”
“Crop”
“Unit Number”
“Acres”
“Legal Description:

Substantive/
Non-Substantive
Substantive
Substantive
Non-Substantive
Non-Substantive
Substantive

_____ Section:
_____ Township:
_____ Range:

6
7

June 2023

_____ Other Land Identifier (e.g., Spanish land grants, metes and bounds,
etc.):”
“Date of Damage”
“Cause of Damage”

FCIC-24040

Substantive
Substantive

205

Exhibit 86
C.

Loss Adjustment Notice of Prevented Planting (Continued)

Notice Information
Item
Element
#
1
Include the following instruction:

2
3

“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.”
“Insured intends to: (Check One)

Substantive/
Non-Substantive
Substantive

Substantive
Substantive

□ Plant a Cover Crop
□ Destroy
□ Plant to Another Crop
□ Graze
□ Hay
□ Unknown
□ Other, explain in the comments section”
D.

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

4

Note: See Para. 503
“I am an agent, employee, or contractor affiliated with the Federal crop
insurance program □ Yes □ No (Check One)”

Substantive

Note: Include instruction for insured to complete.
E.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date of Notice”
2
“Agent’s Printed Name, Signature, Code Number and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
206

Exhibit 87

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.
A.

General Information
Item
#
1
2
3
4
5
6
7
8
9
10
11
12

13
B.

Element
“Insured’s Name”
“Policy Number”
“Crop Year”
“Crop”
“Unit Number”
“Acres”
“Share”
“Practice”
“Appraised Potential”
“Companion Contract □ Yes □ No”
“Field Identification”
“Planting/Replanting Date”
Note: Provide space to enter both dates if applicable and to add
additional dates by field.
“Narrative”

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

Substantive

Required Questions
Item
Element
#
1
“What kind of tillage methods has the insured carried out?”
2
“What kind of weed control practices are being carried out?”
3
“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.”
4
“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.”
5
“What fertilizer program is being followed? Record the type of program
used. If all of the information cannot be obtained, explain.”
6
“What insecticide/pesticide program is being followed? Record the type of
program used. If all the information cannot be obtained, explain.”
7
“Weather Conditions?”
8
“Is an irrigated practice insured on the crop unit being inspected?”
9
“Type of Irrigation System and Average Times Used.”
10 “Is the irrigation system adequate? Yes □ No □ (Check One). If no,
explain.”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive
Substantive

207

Exhibit 87
B.

Growing Season Inspection Report (Continued)

Required Questions (Continued)
Item
Element
#
11 “Is the irrigation water adequate? Yes □ No □ (Check One). If no,
explain.”
12 “Should the insured’s farming operation be inspected at a later date? Yes
□ No □ (Check One). Please explain why or why not.”
13 “Comments”

C.

Substantive/
Non-Substantive
Substantive
Substantive
Substantive

Required Statements
Item
#
1
Certification Statement

Element

Substantive/
Non-Substantive
Substantive

2

Note: See Para. 502
Privacy Act Statement

Substantive

3

Note: See Para. 501
Non-Discrimination Policy Statement

Substantive

Note: See Para. 503
D.

Required Signatures
Item
Element
#
1
“Insured’s Printed Name, Signature and Date”
2
“Loss Adjuster’s Printed Name, Signature, Code Number and Date”

June 2023

FCIC-24040

Substantive/
Non-Substantive
Substantive
Substantive

208