Seed Industry Plus Error & Omissions Application Form

To obtain your quotation please complete the application below. If, during the process, you have any questions please feel free to contact our office utilizing our toll-free number and a farm representative will be happy to assist you.

Call us toll-free at 1-800-268-3675.

If you prefer, you may download and/or print the Seed Grower E&O application form, and mail or fax it to: Farrell Agencies Ltd., PO Box 758, 131 Palliser Way, Yorkton SK S3N 4C6. Fax 306-786-7577.

Business Information

Full Name:*
Form of Entity:
Corporation Name:
Address:*
Home Phone:*
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Work Phone:
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Fax:
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Cell:
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E-mail:*
Years in Business:
Provincial Association Number:
CSI Certificate Number:
Year CSI Certificate:
Number of Full Time Employees:
Number of Part Time Employees:

Total Gross Seed Sales (Seed intended for planting):*

Grain & Oilseed Sales:

Canada $:
USA $:
Other $:

Forage Seed Sales:

Canada $:
USA $:
Other $:
Custom Seed Treating Receipts (if applicable):
Custom Cleaning Receipts (if applicable):
Additional Insured's:

Insurance History

Has applicant ever carried Errors and Omissions insurance?:

Insurer:
Policy #:
Limits:
Expiry:
Has any insurer ever declined, cancelled or restricted coverage?:
Are you aware of any occurance, fact, circumstance, or allegation, which may give rise to a claim, whether insured or not?:
If yes, please explain:
Any previous losses in the past 5 years?:
If yes, please explain including cause of loss, date of loss, and amount of loss:

If you've had two or more claims, please call our office.

Seed Processing Operations:

Employee Name:
Duties (Grader or Sampler):
Certification Number & Year:
Employee Name:
Duties (Grader or Sampler):
Certification Number & Year:
Employee Name:
Duties (Grader or Sampler):
Certification Number & Year:
Limits Required:

I (We) hereby acknowledge that it is a direct consideration of the granting of insurance coverage provided by this program that all requirements and procedures set down by Canadian Seed Institute regarding grading, sale, handling, shipping and storage of seed/seed products are adhered to.

I (We) hereby also acknowledge that entering my (our) email address below has the same power and validity as if I (we) had personally affixed our signature to this application.

Important notice concerning personal information

By providing your email address below, you provide us with your consent for the collection, use and disclosure of your personal information, including that previously collected, for the purposes of communicating with you; assessing your application for insurance and underwriting your policies; evaluating claims; detecting and preventing fraud; analyzing business results and acting as required or authorized by law.

E-Mail:*
Date:*
Comments and questions:
Word Verification: