Form AG-00401 "General Merchandise Warehouse License Proof of Claim" - Minnesota

What Is Form AG-00401?

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 September 23, 2010;
  • 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 AG-00401 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG-00401 "General Merchandise Warehouse License Proof of Claim" - Minnesota

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Plant Protection Phone: 651-201-6011; Fax: 651-2016108
Minnesota Statute 231
General Merchandise Warehouse License Proof of Claim
I, _____________________________, the undersigned, do hereby submit this claim against the general
merchandise warehouse bond/warehouse operator’s legal liability policy of ________________________
for the following:
Item
Amount
Total Claim Value:
Please include any supporting claim documentation with this form and return it to:
Minnesota Department of Agriculture
Attn: Fruit, Vegetable, Grain Unit
625 Robert Street N
St. Paul, MN 55155
Name (please print):
_____________________________________________
Address: ___________________________________________ ______________________________________
City: ________________________________________State:
________Zip:
Phone: ____________________________________ Email: _________________________________________
I certify that the information submitted on this form, is true and correct.
Signed: _______________________________________________________ Date: _______________________
In accordance with the Americans with Disabilities Act, an alternative form of communication is available upon request.
AG-00401 09/23/10
TDD: 1-800-627-3529. MDA is an equal opportunity employer and provider.
Plant Protection Phone: 651-201-6011; Fax: 651-2016108
Minnesota Statute 231
General Merchandise Warehouse License Proof of Claim
I, _____________________________, the undersigned, do hereby submit this claim against the general
merchandise warehouse bond/warehouse operator’s legal liability policy of ________________________
for the following:
Item
Amount
Total Claim Value:
Please include any supporting claim documentation with this form and return it to:
Minnesota Department of Agriculture
Attn: Fruit, Vegetable, Grain Unit
625 Robert Street N
St. Paul, MN 55155
Name (please print):
_____________________________________________
Address: ___________________________________________ ______________________________________
City: ________________________________________State:
________Zip:
Phone: ____________________________________ Email: _________________________________________
I certify that the information submitted on this form, is true and correct.
Signed: _______________________________________________________ Date: _______________________
In accordance with the Americans with Disabilities Act, an alternative form of communication is available upon request.
AG-00401 09/23/10
TDD: 1-800-627-3529. MDA is an equal opportunity employer and provider.