COUNTY NAME	COUNTY NUMBER	FIELDMAN

NOTICE OF:	Loss	NOTE:	Notice of loss or probable loss		1st Loss
	Probable Loss		must be submitted at least 15		2nd Loss
	Replant		days prior to harvest for most		3rd Loss
	Request for APH Appraisal		crops. See policy and/or
	Self Certification Replant       (Company Authorization Required)		provisions for requirements.

CROP	UNIT	SEC	TWP	RGE	SPECIFIC CAUSE AND DATE OF LOSS	ANTICIPATED HARVEST DATE OR ACRES TO BE REPLANTED
Not Selected Barley Canola Corn Flax Oats Potatoes --Russett --White --Red Soybean Sugar Beets Sunflowers Wheat Dry Beans(below) --Blk Turtle Soup --Cranberry --Great Northern --Navy --Pink --Pinto --Small Red
Not Selected Barley Canola Corn Flax Oats Potatoes --Russett --White --Red Soybean Sugar Beets Sunflowers Wheat Dry Beans(below) --Blk Turtle Soup --Cranberry --Great Northern --Navy --Pink --Pinto --Small Red
Not Selected Barley Canola Corn Flax Oats Potatoes --Russett --White --Red Soybean Sugar Beets Sunflowers Wheat Dry Beans(below) --Blk Turtle Soup --Cranberry --Great Northern --Navy --Pink --Pinto --Small Red
Not Selected Barley Canola Corn Flax Oats Potatoes --Russett --White --Red Soybean Sugar Beets Sunflowers Wheat Dry Beans(below) --Blk Turtle Soup --Cranberry --Great Northern --Navy --Pink --Pinto --Small Red
Not Selected Barley Canola Corn Flax Oats Potatoes --Russett --White --Red Soybean Sugar Beets Sunflowers Wheat Dry Beans(below) --Blk Turtle Soup --Cranberry --Great Northern --Navy --Pink --Pinto --Small Red

FIELD REPRESENTATIVE CONTACTED?	Yes	No
LOSS REPORTED TO:	Branch Office	Council Bluffs Office

UNIT	NAME OF SHARING PARTY	NAME OF OTHER INSURANCE COMPANY	POLICY NUMBER