Farm Quote
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Preferred From of Contact
*
Phone
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Number of Dwellings
1-2
3-4
5-6
6+
Are the Dwelling(s) located at the address above?
Yes
No
If you answered No on the question above, please list the address of your dwelling(s)
Acres
Is dwelling on primary premises occupied by:
Owner
Tenant
Unoccupied
Principal farm operation(s)
Grain
Dairy
Livestock
Other
Name of previous carrier
Was policy cancelled or non-renewed
Yes
No
If yes, why?
Dwellings
Year roof last shingled
Fuel used
Gallons
Age of wiring
Central heating system
Yes
No
Space heaters
Yes
No
Age of plumbing
Age of heating plant
Solar heating
Yes
No
Are premises used for any business or professional purpose other than farming?
Yes
No
If yes, please describe:
Does applicant own dog(s)
Yes
No
If yes, what are the breed of dogs
Has dog ever bitten anyone
Yes
No
Are there horses on premises
Yes
No
Number of horses owned
Number of horses boarded
List all losses within the past 3 years (include date, cause of loss and property involved and amount of loss $)
List all machinery owned (include machinery, year, make & model
List all irrigation equipment owned (For Center Pivot list age, manufacturer, span/towers and location)
Total amount of insurance
$
Total Premium
$
LIMITS: Converge L - Personal Liability
$
Coverage M - Medical Payments to Others
$
Submit
Should be Empty: