CROP-HAIL INSURANCE and/or |
2006-NCIS 757 (Rev. 10-2006) |
MULTIPLE PERIL CROP INSURANCE |
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ASSIGNMENT OF INDEMNITY
Approved Insurance Provider’s
Name & Address:
Insured’s Name
Effective Crop Year:
Insured’s Authorized Representative
Crop Name and County Name:
Street or Mailing Address
The insured
assigns to
(Name of Creditor)
of
(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/commodity(ies) shown above.
CONDITIONS
1.This assignment will be binding upon the person(s) who succeed 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 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).
It is understood and agreed that this assignment will be subject to the terms and conditions of the insurance policy.
Insured’s Signature |
Date |
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Witness’ Signature |
Date |
Creditor’s Signature |
Date |
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Witness’ Signature |
Date |
Approved The Insurance Provider hereby approves the foregoing assignment.
Approved Insurance Provider |
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Authorized Representative’s Signature |
Date |
This assignment was filed with the Approved Insurance Provider on
(Month, Day, Year)
(See reverse side of form for statement required by Privacy Act of 1974.)
2006 National Crop Insurance Services, Inc.
COLLECTION OF INFORMATION AND DATA (PRIVACY ACT)
To the extent that the information requested herein relates to your individual capacity as opposed to your business capacity, the following statements are made in accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a). The authority for requesting information to be furnished on this form is the Federal Crop Insurance Act (7 U.S.C. 1501 et seq.) (Act) and the Federal crop insurance regulations contained in 7 C.F.R. chapter IV.
Collection of the social security account number (SSN) or the employer identification number (EIN) is authorized by section 506 of the Act and is required as a condition of eligibility for participation in the Federal crop insurance program. The primary use of the SSN or EIN is to correctly identify you, and any other person with an interest in you or your entity of 10 percent or more, as a policyholder within the systems maintained by the Federal Crop Insurance Corporation (FCIC). Furnishing the SSN or EIN is voluntary; however, failure to furnish that number will result in denial of program participation and benefits.
Your policy also specifies other information that must be provided. The principle purposes of this information are to provide insurance; reinsurance; determine eligibility; determine the correct parties to the agreement; determine and collect premiums or other monetary amounts (including administrative fees and over payments); and pay benefits. The routine uses of this information include: (1) Referral to the appropriate agency, whether Federal, State, local or foreign including the Department of Justice, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule regulation or order issued pursuant thereto, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or particular program statute or by rule, regulation or order issued pursuant thereto; (2) Disclosure to a court, magistrate or administrative tribunal, or to opposing counsel in a proceeding before a court, magistrate or administrative tribunal, of any record within the system that constitutes evidence on that proceeding, or which is sought in the course of discovery, to the extent that FCIC determines that the records sought are relevant to the proceeding; (3) Disclosure to a congressional office in response to any inquiry from the congressional office made at the request of that individual; (4) Disclosure to Approved Insurance Providers (AIP) for any purpose relating to the sale, service, and administration of the Federal crop insurance program and the policies insured under the authority of the Act; (5) Disclosure to other Federal agencies and contractors, cooperators, and partners of FCIC for the purpose of conducting research, development, analyses, and evaluation into all aspects relating to new and existing crop insurance programs and other risk management tools; (6) Disclosure to contractors or other Federal agencies to conduct research and analysis to identify patterns, trends, anomalies, instances and relationships of AIP’s, agents, loss adjusters and policyholders that may be indicative of fraud, waste, and abuse; (7) Disclosure to AIPs, contractors, and other applicable Federal agencies to determine whether information has been accurately provided to FCIC and the AIP’s and to determine compliance with program requirements; and (8) Disclosure to AIPs, contractors, cooperators, partners of FCIC, and other Federal agencies for any purpose relating to the sale, service, administration, analysis and evaluation of the Federal crop insurance program.
Furnishing other information is also voluntary. However, failure to report the information specified in your policy may result in rejection of any claim for indemnity, replanting payment, or other benefit; ineligibility for insurance; a unilateral determination of any monetary amounts due; or any remedy provided in the policy.
NONDISCRIMINATION STATEMENT
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights,1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
