Please complete all sections on the following forms.

A Shackelford representative will contact you with an approximate quotation based on this information. 


Applicant's Information
      Name: 
Auth. Rep.: 
   Address: 
      City:    State:    Zip: 
Home Phone:    Work Phone:    Fax: 
    E-Mail: 


Agency Information
         Name: 
Agency Code #: 
      Address: 
         City:    State:    Zip: 
   Work Phone:    Fax: 

Tax Identification No.: 
SSN  EIN  OTHER (checkone) 
Type of Entity:
Is applicant at least 18 years old?
Yes No 
New Applicant Previously Insured With: 
  Co. Name:
Policy No.:


Persons and/or entities with 10% or more interest in the insurable entity identified above.
       Name            Address     Phone No.     Id No.     SSN/EIN/Other  Entity Type






STATE_____________EFFECTIVE FOR THE_____________AND SUCCEEDING CROP YEARS____LOSS 
PAYABLE TO ME AND_____________ (Attach assignment of Idemnity Form)

     County             Crop       Optional Coverage Type,Class,Etc





     Coverage          Price          Intended         Estimated 
      Level           Election         Acres            Premium






Crops not insured the first year:
Does Applicant have like Insurance on any of the above crops applied for? 
Yes No
 
   The Applicant, subject to the provisions of the regulations of the Federal Crop Insurance
Corporation of the successor, hereby applies to the Company for insurance on the applicant's
share in the crops (applied for on this application) planted or produced, whichever is
applicable, on insurable acreage as shown on the county, actuarial table (or as otherwise
provided in the policy) for the county(ies) identified on this application.  The application
elects, as applicable, the coverage shown on this application.  The premium rate and applicable
production guarantee or amount of insurance per acre shall be those filed in the service
office for each crop year.