Fillable PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS CROP (Risk Placement Services, Inc.)

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PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS CROP (Risk Placement Services, Inc.)

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IA-APP-CROP (08/09) © 2009 X.L. America, Inc. All Rights Reserved. Page 1 of 2
IA-APP-CROP-FL (09/11) May not be copied without permission.
IA-APP-CROP-KY (06/11)
IA-APP-CROP-ME (02/10) IA-APP-CROP-MA (03/10)
Greenwich Insurance Company Indian Harbor Insurance Company
PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS
CROP INSURANCE QUESTIONNAIRE
1. Applicant Name: ____________________________________________________________________
2. Date applicant started placing crop insurance: __________________________________ (MM/YYYY)
3. Does the applicant have any financial interest in another entity that solicits, sells or services crop insuranc
e?
Yes No
4. Does the applicant offer services to other crop agents (i.e. data processing, marketing, etc)?
Yes No
5. Does the applicant appoint other agents or accept crop insurance submissions from other agents?
Yes No
a. If yes, do you have a written sub-producer agreement that includes a hold harmless clause?
Yes No
b. If yes, do you require them in writing to carry E&O insurance with a minimum limit of $500,000 per claim?
Yes No
6. What percentage of the applicant’s staff has attended a crop insurance seminar in the last 12 months? __________%
7. Does the applicant require a signed acreage report by crop for each acreage report being submitted?
Yes No
8. Does the applicant verify acreage data with the following sources? (check all that apply)
Producer/Farmer FSA GPS Mapping Other (describe) _______________________________
9. Does the applicant provide the carrier with all supporting documentation when submitting the acreage report?
Yes No
10. Does the applicant keep a file of all documents sent to the insured and the carrier?
Yes No
11. Does the applicant insure farmers who grow avocados, citrus, nuts or nursery stock?
Yes No
12. Has the applicant been reviewed by the USDA within the past 5 years?
Yes No
If Yes, provide details on a separate sheet of paper
13. Has the applicant had any claims under the Federal Crop Insurance Act or Program Fraud Civil Remedies Act?
Yes No
If Yes, provide details on a separate sheet of paper
FRAUD WARNINGS
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO
COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO D.C. APPLICANTS:
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties
include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by
the applicant.
IA-APP-CROP (08/09) © 2009 X.L. America, Inc. All Rights Reserved. Page 2 of 2
IA-APP-CROP-FL (09/11) May not be copied without permission.
IA-APP-CROP-KY (06/11)
IA-APP-CROP-ME (02/10) IA-APP-CROP-MA (03/10)
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE TO
HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is
a crime punishable by fines or imprisonment or both. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. NOTICE TO LOUISIANA
APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a
crime to knowingly provide false, incomplete or misleading information to an insurance company for purposes of defrauding the company. Penalties
may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully
presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO NEW JERSEY APPLICANTS: Any person who
includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NOTICE TO NEW
MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NOTICE TO NEW YORK
APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each violation. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO
OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO PENNSYLVANIA
APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO RHODE ISLAND
APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefitor knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to fines and confinement in prison . NOTICE TO TENNESSEE APPLICANTS: It is
a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance benefits. NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete
or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of
insurance benefits. NOTICE TO WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO
WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO ALL OTHER
STATE APPLICANTS: Any person who knowingly and willfully presents false information in an application for insurance may be guilty of insurance
fraud and subject to fines and confinement in prison.
Fraud Language updated (02/10)
Date
Agent’s Signature
Printed Name of Signature
Florida License Identification Number of Agent
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PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS CROP (Risk Placement Services, Inc.)

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Completed 23 November 2020

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