Apply :: Syngenta

1. Account Registration

Email Address

Password

2. Seed Advisor/Location Information

Advisor Number

Advisor First Name

Advisor Last Name

Authorized Advisor's Business Name

Advisor Contact - First name

Advisor Contact - Last Name

Advisor Contact Phone

Advisor Contact E-mail

Street 1

City

State/Region

Postal Code

Billing Address (if different)

Street 1

Street 2

City

State/Region

Postal Code

3. Seed Location(s)/Value

Amount Insured/Rate: Invoice value of product and container, not to exceed policy limits described below, rates as follows:

Tier 1: Up to $2,000,000 - $1.15 per $1,000 of invoiced seed
Tier 2: Greater than $2,000,000 - $1.05 per $1,000 of invoiced seed

Seed Locations

Dealer Estimated Seed Value - Total for all Locations

Dealer Seed Brand Name

Seed Location 1

Street 1

City

State/Region

Postal Code

Sub Dealer Enrollment

Amount Insured/Rate: Invoice value of product and container, not to exceed policy limits described below, rates as follows:

Tier 1: Up to $2,000,000 - $1.15 per $1,000 of invoiced seed
Tier 2: Greater than $2,000,000 - $1.05 per $1,000 of invoiced seed

Seed Location 1

Sub Dealer First Name

Sub Dealer Last Name

Street 1

City

State/Region

Postal Code

4. Submission

THE APPLICANT DECLARES THAT, AFTER INQUIRY, TO THE BEST KNOWLEDGE OF ALL PERSONS TO BE INSURED THE STATEMENTS SET FORTH HEREIN AND IN ANY ATTACHMENTS MADE HERETO ARE TRUE, AND NO MATERIAL FACTS HAVE BEEN SUPRESSED, OMITTED, OR MISSTATED.

UNDERWRITERS RESERVE THE RIGHT TO AMEND THE TERMS, CONDITIONS AND LIMITATIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION, IF SUBSEQUENT TO THE DATE OF THIS APPLICATION, BUT PRIOR TO THE INCEPTION OF SUCH POLICY, THERE ARE ANY MATERIAL ALTERATIONS TO THE INFORMATION CONTAINED HEREIN.

COMPLETION OF THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO PROVIDE COVERAGE, BUT IT IS AGREED THAT THE STATEMENTS AND PARTICULARS CONTAINED HEREIN WILL BE RELIED UPON BY UNDERWRITERS IN THE EVENT A POLICY IS ISSUED. THIS APPLICATION IS SIGNED ON BEHALF OF ALL OWNERS, PRINCIPALS, PARTNERS, SHAREHOLDERS, DIRECTORS AND EMPLOYEES.

BY SUBMITTING THIS APPLICATION, THE APPLICANT AGREES THAT IN THE EVENT THE APPLICATION CONTAINS MISREPRESENTATIONS OR FAILS TO STATE FACTS MATERIALLY AFFECTING THE RISK ASSUMED BY THE INSURING COMPANY UNDER A POLICY ISSUED, THE POLICY MAY BE DEEMED NULL AND VOID.

5. Warranty Signature

By typing your name into the field below, you are affixing an electronic signature to a legal document and by doing so, you agree to be bound by the terms and provisions set forth in this application.

Name

Signature

Date