- The Growers’ Broker Special One . Insurance Brokers Helping you to protect your crop returns. Crop Insurance Information Sheet Peter Please complete to request a quote or to request cover and fax to 02.6752 1033 or e-mail to insurance@wsoc.com.au Contact Name: NGR: ‘Trading Name: ABN: Property Name & Address Postal Address: Shire: Phone: Mobile: Direction & kims to nearest town: Em Do you wish to insure your crops now? Yes No. Do you only require a quotation? Yes No NB: Cover cannot be confired unt al of the requied datas have been provided to the sue Paddock Name Crop Type e.9. Wheat ‘Area (ha) Est. Yield (ha) | Value (S/tonne) 1 2 3 4 5 6 7 8 9 10 1 2 13 14 15 ‘Are any of your crops damaged? Yes No ‘Are you insuring all of your crops? Yes No Ifno, a map is required detailing insured and uninsured crops. Have you suffered any crop losses in the last 5 years?? Yes No_If Yes please provide details below. Date: Cause: Loss $ Policy Type Required: After Harvest Declaration Final Revision Date Cover Required: Hall &Fire Fire Only ‘Are any of your crops share farmed? Yes No _If Yes, please complete details below. ‘Sharefarmers Name: Phone: % Share: Does your sharefarmer wish to insure their share of the crop? Yes No. Your signature Date 1 1 2010 ‘Speclal One Francia Sericos Pty Lid. ABN 64 136 637 S38. AFSL $88960. Tel (02)6752 1022 Tho undersigned acknowledges hat the infrmaton or dat collected on this fom by Special One Facil Series ty Lie SOF may be Used for areting purposes for SOFS andi parent crmpary Walgett Special One Co-operative. Special (One Panel! Services Pry Ld nereby cached tat the infomation is colt forthe purpose and the underaigned nereby consents ta the closure fs infrmaion pursuant to Prnipal 17 (of the Information Privacy rncples enuncite by tue of section 18 ofthe Privacy Act 186.