Agronomy Complaint Form

Agronomist Name*
First Last
Date*
MM slash DD slash YYYY
CUSTOMER INFORMATION
Customer Name
First Last
Customer Address
Street Address Address Line 2 City State ZIP Code
Customer Phone
Customer Email
FIELD LOCATION
Farm Name
Field Name
Crop
Address
Street Address Address Line 2 City State
COMPLAINT INFORMATION
Date Observed
MM slash DD slash YYYY
Observed By
First Last
Applicator Name
First Last
Date of Application
MM slash DD slash YYYY
Custom Application Report Number
Applicator Comments
Recommendations
Additional Information
Potential Claim Amount
Reported to Insurance?
- Yes
- No
- Unsure
If NOT to be turned into insurance, attach a SIGNED Customer Release Form to this document.
Attachment 1
Accepted file types: jpg, jpeg, png, gif.
If you need to submit additional documents, invoices or images, email directly to Centerra Risk Coordinator, Jason Nowakowski at jnowakowski@centerracoop.com
Attachment 2
Accepted file types: jpg, jpeg, png, gif.
If you need to submit additional documents, invoices or images, email directly to Centerra Risk Coordinator, Jason Nowakowski at jnowakowski@centerracoop.com
Attachment 3
Accepted file types: jpg, jpeg, png, gif.
If you need to submit additional documents, invoices or images, email directly to Centerra Risk Coordinator, Jason Nowakowski at jnowakowski@centerracoop.com
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CUSTOMER INFORMATION