"Report of Loss Allegedly Caused by Use of Insecticides, Herbicides, Fungicides and Other Pesticides" - Oregon

Report of Loss Allegedly Caused by Use of Insecticides, Herbicides, Fungicides and Other Pesticides is a legal document that was released by the Oregon Department of Agriculture - a government authority operating within Oregon.

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Report of Alleged Loss Due to Pesticides Form
Pesticides Program
503.986.4635
Form date 1/21
What is a loss?
Any person who claims to have sustained any loss arising out of the use or application of any pesticide may file
a report of loss with the Oregon Department of Agriculture. Examples of loss may include but are not limited to:
crop, ornamental, pasture, property, animals and/or individuals.
Who should file a “report of loss” form?
To claim a loss from the use of a pesticide by a commercial pesticide operator, you must file a “report of loss”
form with the Department of Agriculture. According to the Liability Claims Procedure in Oregon Revised
Statutes (ORS 634.172), filing a “report of loss” protects your right to pursue civil action against the
commercial pesticide operator. The word “pesticide” includes fungicides, herbicides, insecticides, defoliants,
desiccants and plant growth regulators. A “commercial pesticide operator” means someone who applies
pesticides for hire.
You may also file a “report of loss” to claim a loss stemming from the use of a pesticide by a non-commercial
operator, which includes any person—other than a commercial operator—who uses a pesticide.
When to file a “report of loss”
You must file the “report of loss” within 60 days of the pesticide application or your discovery of the loss. If the
loss deals with a growing crop, you must file before 50% of the affected crop is harvested.
Investigations
The Oregon Department of Agriculture may conduct an investigation in response to a “report of loss”. Although
the Department will record all “reports of loss”, limited resources restrict investigations to certain types of
situations. If the Department conducts a “report of loss” investigation, investigators will seek to determine the
extent and nature of an alleged loss. Investigations will not determine the source of the damage, the person
who may have caused the damage, or the extent of the financial damage. Furthermore, the Department cannot
require an operator to pay for a claimed loss.
Enforcement action
A “report of loss” investigation will not, of itself, result in the Department taking enforcement action against a
commercial pesticide operator. However, a “report of loss” investigation may result in a “follow-up”
investigation to determine the lawfulness of a specific pesticide application. This, in turn, could lead to an
enforcement action by the Department against the commercial pesticide operator.
Legal assistance
The Oregon Department of Agriculture cannot act as your legal counsel. If you have questions concerning your
legal rights, you should contact an attorney.
Important:
ORS 634.172 requires the claimant to send or personally deliver a true copy of the completed Report of Loss
form to the operator who did the application and to the Landowner (renter) for whom the application was done.
Additional information
If you have questions regarding the “report of loss,” including filling out appropriate forms, contact:
Oregon Department of Agriculture
Pesticides Program
635 Capitol St. NE, Salem OR 97301-2532
(Phone: 503.986.4635)
RETAIN THIS SHEET FOR YOUR INFORMATION
Report of Alleged Loss Due to Pesticides Form
Pesticides Program
503.986.4635
Form date 1/21
What is a loss?
Any person who claims to have sustained any loss arising out of the use or application of any pesticide may file
a report of loss with the Oregon Department of Agriculture. Examples of loss may include but are not limited to:
crop, ornamental, pasture, property, animals and/or individuals.
Who should file a “report of loss” form?
To claim a loss from the use of a pesticide by a commercial pesticide operator, you must file a “report of loss”
form with the Department of Agriculture. According to the Liability Claims Procedure in Oregon Revised
Statutes (ORS 634.172), filing a “report of loss” protects your right to pursue civil action against the
commercial pesticide operator. The word “pesticide” includes fungicides, herbicides, insecticides, defoliants,
desiccants and plant growth regulators. A “commercial pesticide operator” means someone who applies
pesticides for hire.
You may also file a “report of loss” to claim a loss stemming from the use of a pesticide by a non-commercial
operator, which includes any person—other than a commercial operator—who uses a pesticide.
When to file a “report of loss”
You must file the “report of loss” within 60 days of the pesticide application or your discovery of the loss. If the
loss deals with a growing crop, you must file before 50% of the affected crop is harvested.
Investigations
The Oregon Department of Agriculture may conduct an investigation in response to a “report of loss”. Although
the Department will record all “reports of loss”, limited resources restrict investigations to certain types of
situations. If the Department conducts a “report of loss” investigation, investigators will seek to determine the
extent and nature of an alleged loss. Investigations will not determine the source of the damage, the person
who may have caused the damage, or the extent of the financial damage. Furthermore, the Department cannot
require an operator to pay for a claimed loss.
Enforcement action
A “report of loss” investigation will not, of itself, result in the Department taking enforcement action against a
commercial pesticide operator. However, a “report of loss” investigation may result in a “follow-up”
investigation to determine the lawfulness of a specific pesticide application. This, in turn, could lead to an
enforcement action by the Department against the commercial pesticide operator.
Legal assistance
The Oregon Department of Agriculture cannot act as your legal counsel. If you have questions concerning your
legal rights, you should contact an attorney.
Important:
ORS 634.172 requires the claimant to send or personally deliver a true copy of the completed Report of Loss
form to the operator who did the application and to the Landowner (renter) for whom the application was done.
Additional information
If you have questions regarding the “report of loss,” including filling out appropriate forms, contact:
Oregon Department of Agriculture
Pesticides Program
635 Capitol St. NE, Salem OR 97301-2532
(Phone: 503.986.4635)
RETAIN THIS SHEET FOR YOUR INFORMATION
Instructions for Completing a Report of Loss Form
Lack of complete critical information may cause ODA to return the Report of Loss form for further information.
1. & 2. Date of claimed pesticide application; Date of Loss (or discovery of damage): Month, day and year.
3.
Pesticide product name: Provide as much information as possible to identify the pesticide or pesticides
used. For example: manufacturer and trade name (XYZ Chemical Company 2,4-D UHV Weed Killer). The EPA
registration number will be very helpful. Lacking the manufacturer, trade name or EPA registration number,
identify the pesticide by name of the active ingredient or common chemical name.
4.
Describe loss: Be as specific as possible. Name and type of crop (winter wheat or spring wheat; seed
potatoes or market potatoes), variety name, ornamentals, pasture, animals (cattle, sheep, bees, chickens), or
individuals affected. Indicate size as acres, number of plants or number of animals or individuals. If a health care
professional or veterinarian is involved, please provide their name, address and telephone number.
5.
Non-performance: The Report of Loss procedure is not intended for incidents where the pesticide or
application did not accomplish its intended purpose. The immediate cause of the problem must be due to the
pesticide, not a secondary cause of the pesticide. For example: An insecticide is applied but does not kill the
grasshoppers. Subsequently, the grasshoppers destroy the crop. The immediate cause of the crop damage is
the insect; the secondary cause of the problem is the insecticide. This example would constitute
non-performance of the pesticide and would not qualify under the Report of Loss procedures.
6.
If damage to a growing crop, has 50% of the crop been harvested? Answer yes or no. Typically, ODA
will not investigate an incident where evidence of the damaged crop or property has been removed from the
site where the damage occurred.
7.
Who made the pesticide application (choose one) and list the name, address and phone number.
8.
Landowner (or renter) for whom the pesticide was applied: Name, address and telephone number of
the person, business or agency who contracted for the pesticide application to be made.
9.
Suspected cause or source of the damage: Indicate by marking appropriate selections. Explain “other.”
10. Statement of facts concerning the pesticide application and claimed damage. Provide as much factual
information as possible concerning the incident. A graphical representation such as a drawing or map showing
affected areas in relation to the source of the pesticide will be very helpful.
11. History of pesticides, fertilizers, and other chemicals used by you or the previous occupant on damaged
site (attach additional sheets if necessary).
12. Other investigators: People such as extension agents, cannery fieldpersons, private consultants,
veterinarians, doctors, insurance agents, pesticide manufacturer representatives and representatives of other
government agencies who have observed or investigated this incident.
13. Authentication: Sign the Report of Loss form, provide your printed name, your address, city, state, zip
code, phone number and the date you signed the form.
Copy Distribution (four copies total needed):
First:
Oregon Department of Agriculture
Second:
Pesticide Operator
Landowner (renter) who hired the work done
Third:
Fourth:
Claimant
Important:
ORS 634.172 requires the claimant to send or personally deliver a true copy of the completed Report of
Loss form to the operator who did the application and to the Landowner (renter) for whom the application
was done.
Special Instructions:
Attach a map or drawing referencing known points such as streets, roads, towns, directions common
landmarks to the Report of Loss. This map will insure the ODA representative can locate your property.
Report of Loss Allegedly Caused by
Use of Insecticides, Herbicides, Fungicides
and Other Pesticides
Form date 4/19
TO: OREGON DEPARTMENT OF AGRICULTURE
PESTICIDES PROGRAM
635 CAPITOL ST. NE
SALEM, OR 97301-2532
1. Date of claimed pesticide application:
2. Date of loss (or discovery of damage):
3. Pesticide used or product name:
4. Description of loss (crop, ornamentals, pasture, property, animals, and/or individuals, etc.) If a health care professional or
veterinarian is involved, please provide their name, address and phone number:
5. Is claim due to pesticide non-performance (failure to control insects, weeds or other pests)?
No
Yes
6. If damage to growing crop, has 50% of crop been harvested?
No
Yes
7. Who made the pesticide application (check one):
Commercial Operator
Farmer or Forester
Unknown
Other (specify) Name:
Address:
City, State, Zip:
Phone:
8. Landowner (or renter) for whom pesticide was applied:
Name:
Address:
City, State, Zip:
Phone:
9. Suspected cause or source of damage (mark all appropriate):
Ground application
Air application
Neighbor spraying
Other
10. Statement of facts concerning pesticide use and claimed damage:
Time of day:
Weather:
Age or stage of maturity of damaged property at time of alleged damage:
11. History of pesticides, fertilizers, and other chemicals used by you or the previous occupant on damaged site (attach additional sheets if
needed):
12. Have other investigators observed the damage?
Yes
No
Name(s):
Affiliation:
13. The above information is true and correct to the best of my knowledge and I understand the Oregon Department of Agriculture may
investigate this claim of loss in order to determine the extent and nature of damage allegedly caused. I agree to allow the said
Department reasonable access to any of my property or records in order to carry out these activities.
Signature: Print
Date:
Name:
Address:
City, State, Zip:
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