Form AG01036 Part A "Compensation Claim for Crops Destroyed by Elk" - Minnesota

What Is Form AG01036 Part A?

This is a legal form that was released by the Minnesota Department of Agriculture - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 11, 2021;
  • The latest edition provided by the Minnesota Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AG01036 Part A by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG01036 Part A "Compensation Claim for Crops Destroyed by Elk" - Minnesota

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625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Plant Protection Division, Phone: 651-201-6020, Fax: 651-201-6108
MN STAT. 3.7371, MN RULES CHAPTER 1506
Compensation Claim for Crops Destroyed by Elk
PART A.
To be completed by Owner
Claim # (MDA will fill this in):
Owner Name:
Phone:
Address:
City:
State:
Zip:
Was the crop covered by insturance?
Yes
No
If yes, policy number:
Insurance agent:
Phone:
Have you received compensation for these losses from any other source?
Yes
No
If yes, amount $
Loss 1
County and Township/Range/Section where loss occurred:
Description of damage and evidence leading claimant to believe damages were caused by elk:
Date loss discovered:
Date loss reported:
Name of approved agent notified:
I have inspected the destroyed or damaged crop and find that the above described loss occurred, that the evidence indicates the
crop was damaged or destroyed more probably than not by elk and that the above descriptions are accurate.
________________________________________________________________
_____________________
Owner Signature
Date
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG01036
03/11/21 Page 1 of 2
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Plant Protection Division, Phone: 651-201-6020, Fax: 651-201-6108
MN STAT. 3.7371, MN RULES CHAPTER 1506
Compensation Claim for Crops Destroyed by Elk
PART A.
To be completed by Owner
Claim # (MDA will fill this in):
Owner Name:
Phone:
Address:
City:
State:
Zip:
Was the crop covered by insturance?
Yes
No
If yes, policy number:
Insurance agent:
Phone:
Have you received compensation for these losses from any other source?
Yes
No
If yes, amount $
Loss 1
County and Township/Range/Section where loss occurred:
Description of damage and evidence leading claimant to believe damages were caused by elk:
Date loss discovered:
Date loss reported:
Name of approved agent notified:
I have inspected the destroyed or damaged crop and find that the above described loss occurred, that the evidence indicates the
crop was damaged or destroyed more probably than not by elk and that the above descriptions are accurate.
________________________________________________________________
_____________________
Owner Signature
Date
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG01036
03/11/21 Page 1 of 2
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
To be completed by the Minnesota Department of Agriculture
Claimant vendor #
Claim total
Less insurance or other compensation
Amounts of previous claims paid during
the current fiscal year
Reasons why claim reimbursement is
less than claim total
Claim reimbursement
Agent vendor number
Loc No:
Purchase order number
Loc No:
________________________________________________________________
_____________________
Signature, MDA
Date
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG01036
03/11/21 Page 2 of 2
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
Page of 2