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Head Office:
Corner of Broadway
and Myrtle Avenue
in downtown Yorkton, SK

Seed Industry Plus
Errors & Omissions Application

  
Satellite Offices:
Bredenbury
Churchbridge
Foam Lake
Wishart

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 application form and mail or fax it to the address or fax number at the bottom of this page.

Fields marked with * are required before form can be sent.

Business Information
Name: *
Form of entity: Corporation
Partnership
Sole proprietorship
Joint venture
Corporation name:
Mailing address:
City/Town: *
Province:
Postal Code:
Home phone: *
Work phone:
Cell phone:
Fax:
Email: *
Years in business:
Provincial association #:
Number of employees:
Full time:
Part time:
Seed sales (seed intended for planting):
Total gross seed sales: *$
In Canada:$
In USA:$
In other countries:$
Custom cleaning receipts (if applicable): $

Insurance history
Has applicant ever carried Errors and Omissions insurance?
Yes
No
If Yes:
Insurer:
Policy number:
Expiry date:
Limits:

Has any insurer ever declined, cancelled or restricted coverage?
Yes
No

Are you aware of any occurrence, fact, circumstance or allegation which may
give rise to a claim, whether insured or not?
Yes
No
If Yes, please explain:



Has applicant had any losses in the past 5 years?
Yes
No
If Yes:
Cause of loss:
Date of loss:
Amount of loss:$
If you've had two or more claims, please call our office.

Seed processing operations
Employee name:
Duties:
Certification # and year:

Employee name:
Duties:
Certification # and year:

Employee name:
Duties:
Certification # and year:



Limits required: $50,000 per claim, $100,000 aggregate
$250,000 per claim, $500,000 aggregate
$500,000 per claim, $1,000,000 aggregate
$1,000,000 per claim, $1,000,000 aggregate

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.


Email address:
Date:

Comments and questions


  

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
41 West Broadway
Yorkton SK S3N 0L6

Fax 306-786-7577
Phone 306-783-4477 or 1-800-268-3675 toll-free


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