First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
State of Residence
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Do you grow soybeans?
*
Yes
No
Do you believe that your soybean crops were damaged by off-target movement of dicamba from a neighboring or nearby farm (i.e., a farm not owned or operated by you)?
*
Yes
No
Approximately how many acres of your soybeans do you believe were damaged by off-target movement of dicamba?
*
What do you estimate your monetary losses as a result of off-target movement of dicamba to your soybean crops to be?
*
What type of documents do you have that support your claim of dicamba damage to soybean crops? (check all that apply)
*
Reports of an administrative agency (e.g., state department of agriculture or USDA)
Reports of insurance adjusters or inspectors
Reports of any weed scientists or university professors
Reports from inspection by Monsanto or BASF
Reports from crop scouts or other consultants
Reports from an applicator who sprayed dicamba on a nearby farm
None of the above
Other (Please Describe)
Do you have any photos or videos showing your damages crops?
*
Yes
No
Did anyone other than you witness/observe the damage to your soybean crops?
*
Yes
No
Did you ever file a complaint regarding your crop damage with any administrative agency (e.g., a state department of agriculture or the USDA)?
*
Yes
No
Is there anything else you would like us to know about your potential claim?
Detected Location
Submit
Should be Empty: