Policyholder - Collection of Information and Data Statement
The following statement must be included on any form the individual signs or provided to the individual
on separate form, for each form that is signed by the individual. A copy must be maintained by the
approved insurance provider. For agents and loss adjusters, also refer to
Manager’s Bulletin MGR-08-018 for the 2009 and subsequent reinsurance years.
COLLECTION OF INFORMATION AND DATA
Agents, Loss Adjusters, and Policyholders
(PRIVACY ACT) STATEMENT
The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a):
The Risk Management Agency (RMA) is authorized by the Federal Crop Insurance Act (7 U.S.C. 1501-1524)
or other Acts, and the regulations promulgated thereunder, to solicit the information requested on
documents established by RMA, or by approved insurance providers (AIPs), that have been approved by
the Federal Crop Insurance Corporation (FCIC), to deliver Federal crop insurance. The information is
necessary for AIPs and RMA to operate the Federal crop insurance program, determine program eligibility,
conduct statistical analysis, and ensure program integrity. Information provided herein may be furnished
to other Federal, State, or local agencies, as required or permitted by law, law enforcement agencies,
courts or adjudicative bodies, foreign agencies, magistrate, administrative tribunal, AIPs contractors
and cooperators, Comprehensive Information Management System (CIMS), congressional offices, or entities
under contract with RMA.
For insurance agents, certain information may also be disclosed to the public
to assist interested individuals in locating agents in a particular area. Disclosure of the information
requested is voluntary. However, failure to correctly report the requested information may result in the
rejection of this document by the AIP or RMA in accordance with the Standard Reinsurance Agreement
between the AIP and FCIC, Federal regulations, or RMA-approved procedures and the denial of program
eligibility or benefits derived therefrom. Also, failure to provide true and correct information may
result in civil suit or criminal prosecution and the assessment of penalties or pursuit of other remedies.
For more information, contact Pam Bollinger.