Ncis 757 PDF Details

his form is used when the policyholder wants to assign their payment rights to someone else, such as a lender, landlord, or other entity. By completing the form, the policyholder authorizes the National Crop Insurance Services to make indemnity payments directly to the assigned party. The form must be signed by both the policyholder and the assignee and submitted to the National Crop Insurance Services for processing.

You might find it beneficial to know how much time you'll need to complete this ncis 757 and exactly how long the form is.

QuestionAnswer
Form Name NCIS 757
Form Length 2 pages
Fillable? Yes
Fillable fields 27
Avg. time to fill out 5 min 58 sec
Other names ncis 2019 assignment of indemnity form, ncis 757 online, ncis757, assignment of indemnity

Form Preview Example

CROP-HAIL INSURANCE and/or

2018-NCIS 757_Rev 07-2018

MULTIPLE PERIL CROP INSURANCE

ASSIGNMENT OF INDEMNITY

Approved Insurance Provider’s Name & Address:

Insured’s Name

Insured’s Authorized Representative

Street or Mailing Address

 

 

Crop(s)

Policy Number

City

State

Zip Code

County(ies)

Effective Crop Year

The insured

assigns to

(Name of Creditor)

of

(Street and/or Mailing Address)

(City, State and Zip Code)

the right and interest of any indemnity payment(s) which may be payable to the insured under the insurance policy for

the county(ies)/commodity(ies) shown above.

CONDITIONS

1.This assignment will be binding upon the person(s) who succeeds the Insured’s interest in the insurance policy.

2.Indemnity payments made under the insurance policy will be subject to a deduction for any indebtedness due this Approved Insurance Provider by the Insured.

3.This assignment will not grant the Creditor any greater rights than originally held by the Insured.

4.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.

5.The Approved Insurance Provider will determine the person(s) entitled to any indemnity payment(s) and the payment(s) will be by joint check.

6.If the assignment is not cancelled according to item 7 below, the assignment will cease at the end of the effective crop year.

7.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).

This assignment was filed with the Approved Insurance Provider on _________________, ______ at __________a.m./p.m.

[MONTH] [DAY] [YEAR] [INSERT HOUR]

(See Reverse Side for Required Statements & Signature Blocks)

2018-NCIS 757_Rev 07-2018

Page 1 of 2

© 2018 National Crop Insurance Services, Inc.

COLLECTION OF INFORMATION AND DATA (PRIVACY ACT) STATEMENT

Agents, Loss Adjusters and Policyholders

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 RMA-approved 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.

NONDISCRIMINATION STATEMENT

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).

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 https://www.ascr.usda.gov/ad-3027-usda-program-discrimination-complaint-form, 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, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or email at program.intake@usda.gov.

Persons with Disabilities

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible State or local Agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) 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.

It is understood and agreed that this assignment will be subject to the terms and conditions of the insurance policy.

Insured’s Printed Name

 

Insured’s Signature

Date

Witness’ Printed Name

 

Witness’ Signature

Date

Creditor’s Authorized Representative Printed Name

 

 

 

Creditor’s Authorized Representative Signature

Date

 

Creditor’s Authorized Representative’s Telephone Number

 

 

 

Witness’ Printed Name

 

 

 

 

 

Witness’ Signature

Date

 

AIP’s Authorized Representative’s Printed Name

 

AIP’s Authorized Representative’s Signature

Date

2018-NCIS 757_Rev 07-2018

Page 2 of 2

© 2018 National Crop Insurance Services, Inc.

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