AGENCY INFO

Name:

Phone:

Contact:

Agency Code:

Fax:

Email*:





APPLICANT INFO

Name*:

Entity Type*:

Mailing Address*:

City*:

County*:

State*:

Phone*:

Zip*:

Farm Type*:

Total Acres:

Total Locations:

Locations w/ Buildings:





LOCATION INFO

Address*:

City*:

County*:

Section*:

State*:

Township*:

Zip*:

Range*:

Inside City Limits?*

YesNo





LIABILITY COVERAGE(S)

Liability Limit:

Medical Payments Limit:

Any business activities other than farming or ranching conducted at any insured location?*

If yes, please describe:

Any ATV’s? YN Please Describe (How Many)

Any Horses? YN Please Describe (How Used, How Many?)

Optional Coverages:





DWELLING

Costimator is required for all dwellings over $500,000; Must be insured to at least 80% of value.

Perils: BasicBroadSpecial/BroadSpecialContents Only

Deductible: $1,000$2,500$5,000

Contents Limit: 50%60%70%

Valuation*: Replacement CostActual Cash Value

Any Wildfire or Brush concerns within ¼ mile of Structures/Property? YN Please Describe





DWELLING INFO

Year Built:

Mobile Home:

Living Area Total sq ft:

Select: PrimarySecondaryTenant Occupied

Construction:

Amount of Insurance: $

Roof Type:

If Mobile, foundation*: YesNo

Value at 100% Replacement Cost: $

Updates:

Wiring Year:

Plumbing Year:

Heating Year:

Roof Year:

Garage sq ft:

AttachedDetached

Wood Stove*: YesNo

PROTECTIVE DEVICES

Protective Devices*: YesNo

If Yes, describe:

Fire Protection: Within 5 miles of fire dept*: YesNo

Within 1000 ft of hydrant*: YesNo

ISO Rating:





SCHEDULED FARM PERSONAL PROPERTY

Year

Make

Model

Peril

Limit

Ded





BARNS AND OUTBUILDINGS

(All values under $4,000: Type 3 - Any open building, all hay barns: Type 2 or 3, Barns over 1 story, Type 2- Must insure at least $7.50 per sq ft)

Open/Closed

Year

Sq Ft

Construction

Roof Type

Peril

Limit

Ded





OPTIONAL PROPERTY OVERAGES

Description

Limit of Insurance (if applicable)





APPLICANT'S LOSS HISTORY(Last 5 years, regardless of location)

*All losses claimed within the past 5 years are stated below. I understand that by not listing any losses below, I am stating that the applicant certifies that there is no loss history to report over the past 5 years.

Date of Loss If exact date of loss is not available, please estimate to best of your ability.

Description

Amount





Premium of Existing/Expiring Policy:





Notes or comments about the risk





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