Farm Quote

Address

Phone Number

Area Code Phone Number
Number of Dwellings
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
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
$
Should be Empty:

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Dwellings