Any individual suffering loss or damage resulting from the use or application by others of any pesticide must file with the department a written report of loss which contains but is not limited to the following information:
The name and address of the claimant; and
The type of property alleged to be damaged; and
The name of the individual applying the pesticide and allegedly responsible; and
The name of the owner or lessee of the property for whom such application of pesticide was made.