Contract Grower Information Form

Primary Contact Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Select One

Checking

Savings

Payment Acknowledgement *

Upon receipt of all the required information and documents listed above we will immediately begin our review/approval process. All required information must be submitted before payment is remitted. Cash disbursements occur monthly as outlined in your contract. If you are paid via ACH, you can expect your payment to arrive in your bank account on the due date stated in your contract. Paper checks will be mailed on the due date and delivered as soon as the USPS can get them delivered. Our goal is to issue payments to all growers on time every time so long as we have been provided with the required information and documents listed above. Any delays in receiving all required information and documents OR discrepancies in the amount will create delays in processing the payment.

I agree

Verification of Insurance Agreement *

I agree to provide verification of insurance based on what is outlined in my Contract and stated below. I also agree that my agent will need to send annual verification of renewal to us before the policy's expiration. When naming Passel as an additional insured, please list it as Passel Farms, LLC 1901 Main St Emmetsburg, IA 50536. “n. To furnish to PF: (i) within five (5) days of the date of this Agreement if this Agreement applies to an existing Grower Facility or (ii) within thirty (30) days prior to the delivery of any Animals to a new Grower Facility, and, in either event, annually thereafter within five (5) days of the anniversary of the date of the first providing to PF such insurance certificate, an insurance certificate evidencing that Grower has the following minimum levels of insurance in full force and effect: (a) general liability insurance, providing both premises operations and products completed operations, with minimum of one million dollars ($1,000,000) combined single limits per occurrence, two million dollars ($2,000,000) annual aggregate, and which insurance policy specifically insures Grower while Grower is performing duties under this Agreement; (b) employer’s liability or worker’s compensation; (c) coverage for bodily injury and property damage liability claims arising from the presence of manure or other animal waste produced at the Grower’s Facility, which coverage is broader than coverage for sudden and accidental claims only (if available); (d) property insurance on the Grower’s Facility with coverage or endorsement for : (i) cause of loss as special or equivalent, (ii) business income coverage with extra expense for a minimum coverage limit equivalent to at least three (3) months gross income, and (iii) builders risk (only if Grower’s Facility is being constructed at the time or is to be constructed after this Agreement is executed). PF will be named as an additional insured under the liability policy or the liability portion of the policy, and the policy may not be cancelled without notice to PF. All insurance required under this Agreement shall be subject to the approval of PF and shall be written through an insurance carrier with an A.M. Best Company rating of A- or better. If all or any portion of the insurance required be this Agreement is terminated for any reason or lapses, or if Grower does not provide proof of insurance as required herein, PF reserves the right to procure said insurance and to deduct and offset the cost of such insurance from any amount due Grower under this Agreement.”

I agree

Information Acknowledgement *

I certify the information contained in this application is accurate, true and completed to the best of my knowledge and understanding. I authorize investigation of all statements contained herein and all information concerning this application and release all parties from all liability for any damage that may result from furnishing same to you.

I agree

Name *

Printed Name acting as electronic signature

First Name

Last Name