Ground Sprayer Applicator Program Supplemental Questionnaire
Full Name
Business Name
Business Type
Year Established
Years of Spraying Experience (Briefly Explain)
Email
*
Phone
*
Website
Address
Street Address
City
State
Country
Enter your country
Postal Code
FEIN (if applicable)
Coverage of Interest
Property
General Liability
Commercial Auto
Workers Compensation
Cyber
Fertilizer Chemical Distribution
Are all products in proper containment?
Yes
No
Please elaborate on the type of containment:
Please advise of any lakes/ponds/rivers and/or protected land within 1500 feet of tanks:
Are chemicals repackaged?
Yes
No
If yes, please describe:
Ground Application
How many acres do you apply herbicides and pesticides (chemicals) to?
Describe the type of crops you apply herbicides and pesticides on:
How many acres do you apply fertilizer to?
Describe the type of crops you apply fertilizer on:
How many acres do you apply anhydrous ammonia (NH3) to?
Are all applicators licensed?
Yes
No
If no, please explain:
What methods are being used when handling dicamba products to prevent accidental drift of the product being applied?
Do you have documented procedures for rinsing your machines between products to prevent contamination?
Yes
No
Do you practice the following:
Monitor the wind/guidelines in place:
Yes
No
Use Maps:
Yes
No
Use GPS:
Yes
No
PPE Worn:
Yes
No
Formalized Training:
Yes
No
Do you hire ground or aerial subcontractors to apply fertilizer or chemicals?
Yes
No
Please describe your involvement (arranges, invoices, supplies product) and any contractual/risk transfer in place:
Have you ever reported a claim that resulted in a covered loss?
Yes
No
If yes, please provide the loss details including the amount paid for all damages:
Mixing/Manufacturing
Do you manufacture or mix fertilizers
Yes
No
If yes, please describe your manufacturing/mixing process (ex: blend only - expand on what products are blended, heat or chemical process, liquid or dry etc...):
Please list all manufactured products and provide SDS sheets if available:
Ammonium Nitrate
Do you store, transport, or otherwise handle any ammonium nitrate?
Yes
No
If yes, please explain, including the type of ammonium nitrate:
Anhydrous Ammonia
Do you have documented training for all NH3 handlers
Yes
No
Are all equipment users trained and provided with PPE?
Yes
No
Do you have emergency water nurse tanks?
Yes
No
Consulting
Please describe your consulting services:
Do you charge a fee for your services?
Yes
No
Do you have written records for all consulting services provided?
Yes
No
Indicate your training and experience
Agronomist
CCA
Other
Please describe "other" training and experience if applicable:
Do you have a lab on site?
Yes
No
Seed
Brands of seed sold:
Pioneer
Asgrow
Syngenta
Corteva
Other
Type of seed:
Corn
Bean
Cover Crop
Wheat
Other
Are guarantees or warranties provided?
Yes
No
If yes, please advice:
Is there documentation tracking each outgoing shipment, including the hybrid/variety and lot number, with the producer signing off before taking possession of the seed?
Yes
No
Is there clear labeling and separation to prevent commingled seed?
Yes
No
Do you treat seed?
Yes
No
Are any other operations performed?
Scouting
Delivery
Cleaning
Are the premises treated for insects/pests to avoid infestation?
In-House
3rd Party
Do you have parent seed?
Yes
No
If yes, is the parent seed:
Developed by you
Purchased
If developed by you, are ou selling to others?
Yes
No
Please advise how/where the parent seed is stored and if stored at more than one location:
Please provide the estimated cash value of the parent seed:
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the answers to questions on this application. He/She certifies that the answers are true, correct and complete to the best of his/her knowledge.
Applicant's Name:
Applicant’s Signature:
Clear
Date Signed:
Agency:
Producer's Signature
Clear
Date Signed: