Vendor Update Form

VENDOR UPDATE FORM
Request Type:*
Keystone Cooperative Employee:*

YesNo
Employee Request:*

Submitting form on behalf of vendorApplying to be a vendor
Vendor Type:*
Vendor Classification:*
Request Type (Applicator):
Request Type (Contractor):
Request Type (Internal):
IMPORTANT – In order to be approved as a vendor of Keystone Cooperative, and before you may provide any goods or services to Keystone, this form must be filled out in its entirety and be approved by an authorized Keystone representative. Approval is conditional upon your completion of any required documents requested by Keystone, such as completion of a contractor or other packet, execution of approved contracts, and submission of proof of insurance. Our individual branches have been informed that they cannot engage a vendor without this form being approved and on file at Keystone’s corporate office.
KEYSTONE EMPLOYEE INFO
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Location:*
Division(s):*

Refined FuelPropaneAgronomySeedGrainFeed / SwanCorp
VENDOR INFO
Contact Name:*

First NameLast Name
Vendor / Company Name:*
Company Name or First & Last Name if company name is available.
Phone Number:*
Cell Number:
Contact Email:*
example@example.com
Website:
Company Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attach W-9:*

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Name of Keystone employee that you're currently working with:*

First NameLast Name
Description of Services:*
Do you have a Certificate of Insurance (COI):*

YesNo
Which company are you working with:

Keystone CooperativeAlliance FeedLegacy FeedNorthwind Pork
VENDOR PAYMENT INFO
Remittance Address Same As Physical:*

YesNo
Remittance Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Remit Email Same as Contact Email:*

YesNo
Remit Email:
example@example.com
ACH Setup - Automatic Clearing House
Take advantage of the simplicity, convenience, and efficiency of ACH payments by scheduling your payments to get automatically deposited into your bank account.

Why Choose ACH payments:
• For simplicity: Allows for less processing
• For convenience: Saves time and reduces paper waste
• For effiency: Promotes on time payments and less risk of payments getting lost

How ACH Payments Work:
You authorize deposits into your bank account. Your account will be credited
the amount indicated on your invoice to our company.
Sign Up For ACH:*

YesNo
Account Type:*

CheckingSavings
Name on Account:*
Bank Name:*
Bank City / State:*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Routing Number:*
Bank Routing Number (Confirm):*
Routing Number Matches!
Routing Number Does Not Match!
Account Number:*
Account Number (Confirm):*
Account Number Matches!
Upload Voided Copy of Check:

Not Required - Used in case account or routing number is incorrect.
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Account Number Does Not Match!
Terms:

I/we authorize Keystone Cooperative, Inc. to deposit to the bank account listed above for payment of its obligations.

I/we understand and agree that any and all changes in my acount information, including requests to terminate this agreement, must be in writing and delivered to company at the above address at least 21 days prior to the next
due date. If the payment due date falls on a weekend or holiday, I/we understand that the payment may be executed on the next business day. I/we agree to fully cooperate with company to correct any processing errors that may occur.

ACH set up could take up to 30 days.
Printed Name:*

First NameLast Name
Title:*
APPLICATOR INFO
Applicator Type:*

AerialDroneGround / Non-Aerial
Chemical Type:*
Below is the list of documents you will need to upload:

Pesticide Applicator Core Permit
Pesticide Applicator License Category 11
Commercial Business Pesticide License Category 11
Part 107 UAS License (Drone)
FAA Part 137 License (Operating Certificate)
FAA Airman Medical Exams: Class 3 (Drone), Class 2 (Plane/Helicopter)
Completed W‑9 (see attached blank W‑9)

Also please include any prepay invoices at this time.
Upload copies of the above documents here:

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Please click the links below to complete the Application Service Agreement & Aerial Applicator Guidelines. Once completed, come back to this form to complete the vendor setup:

Application Services Agreement

Aerial Applicator Guidelines
If you received the Thank You confirmation page, your submission was successful. Please complete the form again only if a correction is required.*

I've completed the Application Services AgreementI've completed the Aerial Applicator Guidelines
CONTRACTOR INFO
What type of products will transported:*
What type of services will be performed:*
Which Keystone locations will be serviced:*
Do You Normally Use Sub-Contractors:*

YesNo
INSURANCE REQUIREMENTS
Certificate of Insurance Minimum Coverage:*

Employer's Liability: $500,000 Each Accident; $500,000 Policy Limit; $500,000 Employee Limit DiseaseGeneral Liability: $1,000,000 Per Occurrence / $2,000,000 Aggregate; Products – Comp/OP$2,000,000 AggregateAuto Liability: $500,000 CombinedSingle Limit (CSL)Workers Compensation: Statutory for State/TerritoryAdditional insurance coverage may be required. The above coverage is Keystone's minimum requirement.
Additional Aerial / Drone Minimum Coverage:*

Aviation & Chemical Liability = $300,000 Per Occurrence Unmanned (Drone)Aviation & Chemical Liability = $500,000 Per Occurrence Manned (Airplane/Helicopter)The insured will provide an endorsement evidencing affirmative coverage for pesticide / herbicide fertilizer application.
Additional Insured:*

Policies maintained shall include an endorsement naming Keystone Cooperative, Inc. as Additional Insured in the areas of General Liability and Auto Liability. The insurance coverage must be Primary Non-Contributory with respect to the named Additional Insured. Proposed language to be included on the COI is as follows:
The certificate holder is an additional insured with respect to the general liability & auto liability coverage, which is primary coverage to the additional insured and other available insurance will be non-contributory as required by written contract.

The name and address on the Certificate of Insurance for the "certificate holder" should be:

Keystone Cooperative, Inc.
770 North High School Road
Indianapolis, IN 46214
Waiver of Subrogation:*

Subrogation rights must be waived in favor of Keystone Cooperative, Inc.
Additional Requirements:*

Coverage has to be placed with insurance with a minimum AM Best rating of A- VII30 days' notice of cancellation or nonrenewal provided to Keystone Cooperative, Inc.
Additional Cargo Coverage:*

Grain: $15,000Fertilizer: $25,000Fuel: $25,000Anhydrous Ammonia: $25,000Lime & Stone: N/ASwine: $50,000
Worker's Compensation Exemption:*

YesNo
Upload Worker's Comp Exemption Documentation:*

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Upload COI - Certificate of Insurance:*

Cancelof
CONTRACTS
All agreements, terms, quotes, order forms, statements of works, proposals, and other documents outlining the arrangement between the vendor and Keystone must be submitted and approved by Keystone’s Legal department prior to any work being performed and/or any goods being provided, as well as any payments being made to vendor.
Description of Contract:*
Put "No Contracts" if not applicable.
Please attach all contracts and supplementary documents (e.g., proposals, order forms, SOWs, etc.):

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ACKNOWLEDGEMENTS
I acknowledge that I have completed this form completely and accurately.
I acknowledge that I have completed this form completely and accurately.

All invoices and statements should be sent via email to AP@keystonecoop.com.
If invoices are mailed, please mail to:

Keystone Cooperative Inc.
770 N High School Rd
Indianapolis, IN 46214

I acknowledge that vendors cannot provide goods or services to Keystone, or receive payment, until this form, and all required documents, have been accepted and approved by an authorized representative of Keystone Cooperative, Inc.
Please verify that you are human:*
Signature:*

Clear
Date:*

MonthDayYear
Date
Application Reference:
Should be Empty:

VENDOR UPDATE FORM

KEYSTONE EMPLOYEE INFO

VENDOR INFO

VENDOR PAYMENT INFO

ACH Setup - Automatic Clearing House

APPLICATOR INFO

CONTRACTOR INFO

INSURANCE REQUIREMENTS

CONTRACTS

ACKNOWLEDGEMENTS