"Canada / New Brunswick Wildlife Damage Compensation Program Application Form" - New Brunswick, Canada

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CANADA · NEW BRUNSWICK
CANADA · NOUVEAU-BRUNSWICK
Agricultural Insurance
Assurance agricole
P.O. Box 6000
C.P. 6000
Fredericton
Fredericton
New Brunswick E3B 5H1
Nouveau-Brunswick E3B 5H1
Tel: 506 453-2185
Tél.: 506 453-2185
Fax: 506 453-7406
Fax: 506 453-7406
Canada / New Brunswick Wildlife Damage Compensation Program
Application Form
1) APPLICANT
Name:
Mailing Address:
Street
City / Town
Province
Postal Code
Telephone:
________________________
Cell:
Email:
Fax:
Corporate Tax No.:
Or S.I.N.:
Do you currently have Agricultural Insurance?
Yes
No
If yes, indicate Producer Id. No.:
2) CONTACT PERSON (if different from applicant)
Name:
Telephone:
Email:
3) CLAIM FOR COMPENSATION
Damage Caused by:
____________________________________________________
Damage Cause to (commodity):
____________________________________________________
Date of Damage Noticed:
____________________________________________________
Location of Loss:
____________________________________________________
Briefly Describe the Loss:
____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Estimated Value of Loss:
____________________________________________________
I certify that the information given in this application is true, correct and complete to the best of my knowledge. I
hereby authorize the New Brunswick Agricultural Insurance Commission or its agents to inspect the damage and
verify this information as required.
Signature of Applicant:
Date:
CANADA · NEW BRUNSWICK
CANADA · NOUVEAU-BRUNSWICK
Agricultural Insurance
Assurance agricole
P.O. Box 6000
C.P. 6000
Fredericton
Fredericton
New Brunswick E3B 5H1
Nouveau-Brunswick E3B 5H1
Tel: 506 453-2185
Tél.: 506 453-2185
Fax: 506 453-7406
Fax: 506 453-7406
Canada / New Brunswick Wildlife Damage Compensation Program
Application Form
1) APPLICANT
Name:
Mailing Address:
Street
City / Town
Province
Postal Code
Telephone:
________________________
Cell:
Email:
Fax:
Corporate Tax No.:
Or S.I.N.:
Do you currently have Agricultural Insurance?
Yes
No
If yes, indicate Producer Id. No.:
2) CONTACT PERSON (if different from applicant)
Name:
Telephone:
Email:
3) CLAIM FOR COMPENSATION
Damage Caused by:
____________________________________________________
Damage Cause to (commodity):
____________________________________________________
Date of Damage Noticed:
____________________________________________________
Location of Loss:
____________________________________________________
Briefly Describe the Loss:
____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Estimated Value of Loss:
____________________________________________________
I certify that the information given in this application is true, correct and complete to the best of my knowledge. I
hereby authorize the New Brunswick Agricultural Insurance Commission or its agents to inspect the damage and
verify this information as required.
Signature of Applicant:
Date: