(Lack of complete critical information may result in return of the Damage Claim form for further information.)
1. & 2. Date of claimed pesticide application; Date of Loss (or discovery of damage): Month, day and year.
3. Pesticide product name: Provide as much information as possible to identify the pesticide or pesticides used. For example: manufacturer and trade name (XYZ Chemical Company 2,4-D UHV Weed Killer). The EPA registration number will be very helpful. Lacking the manufacturer, trade name or EPA registration number, identify the pesticide by name of the active ingredient or common chemical name.
4. Claimant’s property or crop allegedly damaged: Be as specific as possible. Name and type of crop (winter wheat or spring wheat; seed potatoes or market potatoes), variety name, ornamentals, pasture, animals (cattle, sheep, bees, chickens), person. Indicate size as acres, number of plants or number of animals. If a person, provide the name, address and telephone number of health professional involved.
5. Non performance: The Damage Claim report is not intended for incidents where the pesticide or application did not accomplish its intended purpose. The immediate cause of the problem must be due to the pesticide, not a secondary cause of the pesticide. For example: An insecticide is applied but does not kill the grasshoppers. Subsequently, the grasshoppers destroy the crop. The immediate cause of the crop damage is the insect; the secondary cause of the problem is the insecticide. This example would constitute non-performance of the pesticide and would not qualify under the Damage Claim procedures.
6. If damage to a growing crop, has 25% of the crop been harvested? Answer yes or no. Typically, DDA will not investigate an incident where evidence of the damaged crop or property has been removed from the site where the damage occurred.
7. If known, who made the pesticide application (choose one) and list the name, address and phone number.
8. Landowner (or renter) for whom the pesticide was applied: Name, address and telephone number of the person, business or agency who contracted for the pesticide application to be made.
9. Suspected cause or source of the damage: Indicate by marking appropriate selections. Explain “other”.
10. Statement of facts concerning the pesticide application and claimed damage. Provide as much factual information as possible concerning the incident. A graphical representation such as a drawing or map showing affected areas in relation to the source of the pesticide will be very helpful.
11. History of pesticides, fertilizers, and other chemicals used by you or the previous occupant on damaged site (attach additional sheets if necessary).
12. Other investigators: People such as extension agents, cannery fieldpersons, private consultants, veterinarians, doctors, insurance agents, pesticide manufacturer representatives and representatives of other government agencies who have observed or investigated this incident.
13. Authentication: Sign the Damage Claim form, provide your printed name, your address, city, state, zip code, telephone number and the date you signed the form.