PRODUCTION COST INSURANCE Financial Release · 2019-10-31 · PRODUCTION COST INSURANCE Financial...

PRODUCTION COST INSURANCE Financial Release

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Email to: [email protected] Phone: 1-877-606-4277 Fax: 1-306-972-8122

FARM INFORMATION

Legal Farm Name Customer #

Contact Name Home Quarter

Address Phone #

City Cell #

Province Fax #

Postal Code Email

FINANCIAL INFORMATION

Contact for Financials Accountant Producer Corporate Year End

Accountant (Please supply a list of all accountants used)

Name Email

Phone # Fax #

AUTHORIZATION

I authorize Global Ag Risk Solutions to request my financial statements from my accountant on an annual basis for the purpose of receiving a Production Cost Insurance quote.

I authorize Global Ag Risk Solutions to release my contact information and farm acreage to FarmersEdge for the purpose of discussing their products and services.

I authorize Global Ag Risk Solutions to release my contact information, farm acreage, and confirmation of my policy purchase to Bayer CropScience Inc. I authorize Bayer CropScience Inc. to contact me to further discuss potential enrollment opportunities for the BayerValue rebate or any other Bayer CropScience Inc. rebate via phone or electronic messaging.

Yes No

Yes No

Yes No

For the calendar/corporate years of 2009 to present, I authorize the release of my financial statements to Global Ag Risk Solutions. I also authorize verbal inquiries to my Global Ag Representative and/or my Accountant(s), for the processing of my application over the same time frame. In addition, I authorize my Global Ag Representative to access my financial summary data, Production Cost Insurance policy documents, as well as any claims information that I have filed. This information is for discussion purposes only with regards to my Production Cost Insurance. This authorization is valid until December 31st, 2020 or should I be in a claim position, it will be valid until the claim is finalized.

I understand that if I elect to obtain financing, my signature below will also authorize Global Ag Risk Solutions to request from my accountant or myself additional information related to financing approval (i.e., financial statements, personal net worth).

I also understand that if I elect to use other products offered by Global Ag Risk Solutions subsidiary(s), my signature below authorizes Global Ag Risk Solutions to share my information with its subsidiary for the purposes associated with the product(s) provided by the subsidiary.

Producer Signature Advisor


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Farm (Legal Name)

Primary Individual

This consent to collect, use and disclose information is provided by the legal farm (the “Farm”) and/or the individuals (the “Individuals”) set out above. “You” means the Farm and Individuals, collectively.

Information about the Farm and related business and operations ( the “Farm Information”) and the Individuals (the “Personal Information”) may be collected by Global Ag Risk Solutions in a variety of ways, including as provided in a financial release, an application for products/services or other means (such as by you or through your broker, agent or accountant).

The Farm Information and Personal Information may be collected, used and disclosed by Global Ag Risk Solutions for the following purposes (the “Identified Purposes”):

• offering and providing products and services to meet your needs;• establishing and maintaining communications with you;• verifying information you provide in your application;• assessing and underwriting risks on a prudent basis;• determining insurance product prices• investigating and settling claims;• detecting and preventing fraud or other illegal activities;• reporting to regulatory or industry entities;• acting as required or authorized by law; and• to de-identify or otherwise anonymize your Farm Information and Personal Information and use the de-identified or anonymized data,

whether alone or aggregated with other data, for business and analytical purposes, including creating reports, predictive models andbenchmarks, deriving insights and conducting market research. Such de-identified, anonymized and aggregated information and anyderivatives thereof, may be shared by Global Ag Risk Solutions with other persons for business and analytical purposes. Suchinformation cannot be used to identify you or the Farm.

You authorize Global Ag Risk Solutions to collect, use and disclose the Farm Information for the Identified Purposes set out above.

PRIVACY CONSENT

Each Individual hereby consents to the collection, use and disclosure of Personal Information about them as set out in the Global Ag Risk Solutions Privacy Policy available at https://agrisksolutions.ca/about/privacy-policy. In particular, and as further set out in the Global Ag Risk Solutions Privacy Policy:

• Use and Disclosure of Personal Information: Global Ag Risk Solutions may use your Personal Information for the IdentifiedPurposes, and may also disclose your Personal Information to third parties in accordance with the Identified Purposes.

• Service Providers and Location of Information: Each Individual acknowledges that Global Ag Risk Solutions may use service providersoutside of Canada, including in the United States of America, to collect, process and store my Personal Information on Global Ag RiskSolutions’ behalf. While the Personal Information is in another jurisdiction it may be accessed by the courts, law enforcement andnational security authorities of that jurisdiction.

Each Individual consents for Global Ag Risks Solutions to de-identify or otherwise anonymize their Personal Information and use the de-identified or anonymized data, whether alone or aggregated with other data, for business and analytical purposes, including creating reports, predictive models and benchmarks, deriving insights and conducting market research. Such de-identified, anonymized and aggregated information and any derivatives thereof, may be shared by Global Ag Risk Solutions with other persons for business and analytical purposes. Such information is not Personal Information and cannot be used to identify the Individual.

Yes No

CONSENT TO USE OF INFORMATION AND PRIVACY NOTICE


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AGREEMENT

Your signature below confirms your acknowledgement and agreement to the above terms. The Primary Individual listed above: (a) acknowledges and agrees on behalf of both themself and the Farm; and (b) represents that they have all necessary rights, permissions and authority to agree to such terms on behalf of the Farm and to bind the Farm.

Date

Date

Primary Individual (on behalf of the Farm and himself/herself)

Global Ag Risk Solutions Advisor


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ACREAGE HISTORY

Please provide as many years as possible.

Year Seeded Acres Dryland Seeded Acres Irrigated Unseeded and Wet Acres Fallow Total Acres

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020 CROP INTENTIONS

Crop Crop Details Acres Irrigated

Check if Yes Crop Insurance

Yield Target Yield Seed

$/Acre Fertilizer

$/Acre Chemical

$/Acre

Please check any that apply to you or your farm: Ag Retailer Pedigreed Seed Grower Mixed Farm Operation

If you operate a Mixed Farm Operation do you have livestock that you feed production to? Yes No

Do you actively track amounts fed? Yes No


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FORWARD CONTRACTED COMMODITIES

Do you have a current or previous crop share arrangement? Yes No

If yes, please fill in details below. If you have provided previously, you do not need to provide again.

Commodity Type Total Contracted

Bushels Net Contracted Price

Basis or Futures Contract

Value of Basis or Futures

CROP SHARE

2020 Crop Share

Year Name Acres Share Arrangement Relationship Payment Received from Producer or Elevator

2009 – 2019 Crop Share History

Year Name Acres Share Arrangement Relationship Payment Received from Producer or Elevator


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OPERATIONAL INDEPENDENCE

A related party is defined as a business relationship between any person to whom you are related by blood, marriage, adoption or common-law involving control or ownership of a mutual business of any sort, not just agriculture. If yes is answered, please provide name, address, relationship, and a description. Please be specific.

a) Do you have relatives involved in farming with whom you do any business transactions/services either in cash or in kind?

Yes No

b) Do you carry-on the business of farming with any other individuals or entities (such as partnerships, joint- ventures, corporations) in which you do not have an ownership interest?

Yes No

Name/Relationship/Details

c) Do you have an ownership interest in any other entities involved in the business of farming? For example; grain production buying or selling, livestock production, input supply, land?

Yes No


d) Do you share equipment? Yes No


e) Do you share grain storage and/or mix grain with another Producer? Yes No


f) Does anyone other than yourself, make decisions regarding types of crops to grow, inputs to use, and timing of seeding, spraying or harvesting?

Yes No




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g) Do you buy/sell inputs to or from any other party besides an Ag Retailer or buy inputs with another party? Yes No


h) Do you buy or sell grain to or from non-licensed Canadian Grain Commissions? Yes No


i) Do you receive a share or revenue from a crop that you do not grow/own? Yes No


j) Are there transactions in the farm operation that are below fair market value? Yes No


k) List of all taxable entities that report income and/or expenses or who’s income and/or expenses are reported as part of this farmoperation.

NOTES & ADDITIONAL INFORMATION

Please include any additional information that will help us better understand your farm operation

PRODUCTION COST INSURANCE Financial Release · 2019-10-31 · PRODUCTION COST INSURANCE Financial...

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