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United States Department of Agriculture

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System Access Request Forms

NFC Security Access Forms are required to request access to NFC’s Insurance Processing  Systems, or establish Insurance Security Officers. Use of a form reduces errors that can delay the provisioning or de-provisioning of critical access, which can affect users’ ability to complete their duties. For this reason, access requests MUST be submitted on an approved NFC or Agency-developed form.

Note, the  Insurance Processing  Request forms (AD-3100–C-Centralized Enrollment Clearinghouse Form (CLER), AD3100-CA-CLER Security Officer Authorization Form,  AD3100-D-Direct Premium Remittance Form (DPRS),  AD3100-DA-DPRS Security Officer Authorization Form, and AD3100-T-Tribal Insurance Processing Systems Access Request Form (TIPS)) are  listed below.

Form # Description Type, File Size
AD-3100-C Centralized Enrollment Clearinghouse PDF, 167KB
AD-3100-CA CLER Security Officer Authorization PDF, 81KB
AD-3100-D Direct Premium Remittance PDF, 185KB
AD3100-DA DPRW Security Officer Designation Form PDF, 83KB
AD-3100-T TIPS Access Request Form PDF, 223KB

Last Updated / Reviewed: September 25, 2018