Notice of Loss1Form2Review Policy Number(Required)InsuredName / Company(Required)Contact Name(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary Phone(Required)Secondary PhoneAgentAgent NameAgent NumberCity/TownCrop InformationStorm Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time(Required) Hours: Minutes AMPM AM/PMAdd additional policy items by clicking the plus sign (⊕) icon at the end of the row. To remove a policy item, click the minus sign (⊖).Policy Item ## of AcresCrop TypeQrtSecTwnRgeMerType of DamageStage of Growth SelectAlfalfa SdAlfalfa-FoAniseBarleyBeansBeetsBorageBrome GrassBuckwheatCamelinaCanary SeedCanolaCarawayChamomileChick PeasClover SdClover SsdClover SwtCorianderCornCorn SweetCuminDillDry BeansDurumEchiumFaba BeanFenugreekFescue SeedField PeasFlaxForage – TForage SanForage-SorForage-TreGardensGrass SdHayHempHyolaKamutLentilsLinolaLupinsMilletMintMixed CropMustardNigerOatsOnionsPeolaPeasPhacelliaPotatoesQuinoaQuinolaRaspberriesRyeRye FallRye GrassRye WildSafflowerSainfoinSilageSilage BSilage b&TSilage CSilage OSilage TSorghumSoybeansSpeltxStrawberrySugar BeetsSunflowersSunolaTimothyTimothy FoTrefoilTriticaleVetchWheatWheat GrassSESWNENWAllW1W2W3W4W5W6E1E2LightMediumHeavySelectEmergence through 3rd leaf4th leaf to first blossomFirst blossom (50% of plants have blossoms)Blossoms and small pods (1/4" to 1/2")Full podsRipeSwathedGrassJust headedBloomingMilkSoft doughHard doughSeedlingRosetteBudStart of flower7 days after first flower14 days after first flower21 day flowerPoddingVegetativeLeafingBlossomGreen bollBoll ripeningVEVSV1V2V3V4V5V6V7-V10V11-VnVnR1R2R3R4R5R6R71-6 leaf7-10 leaf11-17 leafTasseledSilkedBlisterDentMatureVcR8Pre BudBuddingBloomInitial Seed CurlV1-V3V7V8V9-VnR9Emergence – 3 weeksFlowering – 3 weeksFloweringClusterLeaf numberTasselHeadingSilkFull podded Add RemoveAdd additional policy items by clicking the plus sign (⊕) icon at the end of the row. To remove a policy item, click the minus sign (⊖).Town Nearest the Loss(Required)Residence LocationI reside inStreet AddressQuarterSESWNENWAllSectionTownshipRangeMeridianW1W2W3W4W5W6E1E2Additional InsuranceThe information below is required under the Provincial Insurance Act.Do you have other insurance?(Required) Yes NoAdditional Insurance Information(Required)CompanyAmount Per Acre Add RemovePower of AttorneyIn the event of my absence when your adjuster calls to make an appraisal of this claim, I would like to assign power of attorney(Required) Yes NoI hear-by appointName(Required)Of (nearest town)(Required)Phone(Required)to act for me and on my behalf in the adjustment of the said loss, and in that capacity to make proof of loss and to do all things required by me to done pursuant to the statutory conditions of the said policy, and I hereby ratify all that my said attorney may do in connection with such appraisal and adjustment.Power of Attorney(Required) By checking this box I confirm the above power of attorney information.Notice of Loss Confirmation(Required) By checking this box I am aware that according to the policy under which I am making claim that if for any reason the company is not liable for loss, then I am liable for the expense incurred by the company for investigating said claim, and on demand, I promise to pay the company all such expense.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.