Application for Insurance
0%
Applicant Information
Is this a revision to a previous submission?
x
Yes
No
YCI Group Agency Name
YCI Group Producing Agent Name
Producing Agent Email Address
How Many Person(s) Are Applying for Coverage?
1
2
3
4
5
6
Applicant 1 Information
Applicant 2 Information
Applicant 3 Information
Applicant 4 Information
Applicant 5 Information
Applicant 6 Information
Do You Wish To Add A Business Name?
Yes
No
Full Name of Business
If More Than One Business Name, Please Type One Per Line.
Mailing Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Telephone Number
Desired Effective Date
Have You Had Any Claims In The Past Five Years?
x
Yes
No
How Many Claims?
0
1
2
3
Full Details Loss 1
Please included the date of loss, description of loss and total amount paid.
Full Details Loss 2
Please included the date of loss, description of loss and total amount paid.
Full Details Loss 3
Please included the date of loss, description of loss and total amount paid.
Who Is Your Current Farm Policy Insured With?
ACE Ltd.
Alfa Mutual Insurance Co.
Allianz Group
American Farmers & Ranchers Mutual
American Family Mutual
Auto Owners Insurance Co.
Buckeye State Mutual Insurance Co.
Capital Insurance Group
Cameron Mutual Insurance Co.
Celina Mutual Group
Columbia Insurance Group
Country Financial
Everett Cash Mutual Insurance Co.
FarmAssure
Farm Bureau
Farmers Alliance Mutual Insurance Co.
FCCI Mutual Insurance Holding Co.
Grange Mutual Casualty Co.
Goodville Mutual Casualty Co.
Liberty Mutual
Markel Corp.
MDOW Insurance
Nationwide Mutual Group
Norfolk and Dedham Mutual
SECURA Insurance
State Auto Insurance Co.
QBE Insurance Group
Travelers
Westfield Group
Western Reserve Group
Other
Who Is Your Current Agent?
What Is Your Current Premium?
What Type of Farming Operations Are Performed?
Cattle
Dairy
Equine
Field Crop
Fruits
Hobby Farm
Mushrooms
Nuts
Poultry
Tobacco
Vegetables
Other
Years Farming Experience
Page Break
Number of Locations
0
1
2
3
4
5
6
Location 1 Acres
Location 1 The Same As Your Mailing Address?
Yes
No
What Is The Fire Protection Class?
1
2
3
4
5
6
7
8
9
10
Location 2 Acres
Location 3 Acres
Location 4 Acres
Location 5 Acres
Location 6 Acres
Location 1 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Location 2 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Location 3 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Location 4 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Location 5 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Location 6 Address
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
United States
Page Break
Do You Wish To Add Coverage for Dwelling(s)?
Yes
No
How Many Dwellings Do You Wish To Cover?
0
1
2
3
4
5
6
Dwelling 1 Location
0
1
2
3
4
5
6
Dwelling 2 Location
0
1
2
3
4
5
6
Dwelling 3 Location
0
1
2
3
4
5
6
Dwelling 4 Location
0
1
2
3
4
5
6
Dwelling 5 Location
0
1
2
3
4
5
6
Dwelling 6 Location
0
1
2
3
4
5
6
Dwelling 1 Value
Dwelling 1 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling Covered Perils?
x
Basic
Broad
Special
Dwelling 1 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Dwelling 1 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 1 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 1 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 1 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 1 Square Footage
Dwelling 1 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 1 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 1 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 1 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 1 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 1 Protective Devices
x
Smoke Detectors
Central Station Alarm
Dwelling 2 Value
Dwelling 2 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling 2 Covered Perils?
x
Basic
Broad
Special
Dwelling 2 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Dwelling 2 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 2 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 2 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 2 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 2 Square Footage
Dwelling 2 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 2 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 2 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 2 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 2 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 2 Protective Devices
Smoke Detectors
Central Station Alarm
Dwelling 3 Value
Dwelling 3 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling 3 Covered Perils?
x
Basic
Broad
Special
Dwelling 3 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 3 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 3 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 3 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 3 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 3 Square Footage
Dwelling 3 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 3 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 3 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 3 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 3 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 3 Protective Devices
x
Smoke Detectors
Central Station Alarm
Dwelling 4 Value
Dwelling 4 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling 4 Covered Perils?
x
Basic
Broad
Special
Dwelling 4 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 4 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 4 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 4 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 4 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 4 Square Footage
Dwelling 4 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 4 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 4 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 4 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 4 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 4 Protective Devices
x
Smoke Detectors
Central Station Alarm
Dwelling 5 Value
Dwelling 5 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling 5 Covered Perils?
x
Basic
Broad
Special
Dwelling 5 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 5 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 5 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 5 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 5 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 5 Square Footage
Dwelling 5 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 5 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 5 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 5 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 5 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 5 Protective Devices
x
Smoke Detectors
Central Station Alarm
Dwelling 6 Value
Dwelling 6 Occupancy
x
Owner Occupied/Primary
Owner Occupied/Secondary
Tenant Occupied
Dwelling 6 Covered Perils?
x
Basic
Broad
Special
Dwelling 6 Year Built
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 6 Heating Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 6 Wiring Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 6 Plumbing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 6 Square Footage
Dwelling 6 Roofing Update Year
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Dwelling 6 Construction
Frame
Joisted Masonry
Non Combustible
Fire Resistive
Mobile Home
Dwelling 6 Roof Type
Architectural Shingle
Composition Shingle
Metal
Rubber
Slate
Dwelling 6 Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$75,000
$100,000
Dwelling 6 Valuation
x
Replacement Cost
Actual Cash Value
Dwelling 6 Is Your Dwelling Vacant?
x
Yes
No
Dwelling 6 Protective Devices
x
Smoke Detectors
Central Station Alarm
Page Break
Do You Wish To Cover Your Farm Machinery and Equipment?
Yes
No
How Many Items Do You Wish To Cover?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Do You Have More Than 15 Items of Farm Machinery or Equipment?
x
Yes
No
Please let us know the description of the machinery and/or the equipment for the items in excess of 15 and the total value of those items that exceed 15.
Machinery and Equipment Deductible?
x
$1,000
$2,500
$5,000
$10,000
$25,000
Subject to Underwriting Review
Item 1 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Machinery and Equipment Perils?
x
Basic
Broad
Special
Item 1 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Irrigation Equipment
Irrigation Pivot
Incinerator
Lawn Mower
Litter Windrower
Misc.Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 1 Make
Item 1 Value
Item 2 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 2 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 2 Make
Item 2 Value
Item 3 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 3 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 3 Make
Item 3 Value
Item 4 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 4 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 4 Make
Item 4 Value
Item 5 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 5 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 5 Make
Item 5 Value
Item 6 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 6 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 6 Make
Item 6 Value
Item 7 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 7 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 7 Make
Item 7 Value
Item 8 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 8 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 8 Make
Item 8 Value
Item 9 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 9 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 9 Make
Item 9 Value
Item 10 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 10 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 10 Make
Item 10 Value
Item 11 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 11 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 11 Make
Item 11 Value
Item 12 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 12 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 12 Make
Item 12 Value
Item 13 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 13 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 13 Make
Item 13 Value
Item 14 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 14 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Pivot
Irrigation Equipment
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 14 Make
Item 14 Value
Item 15 Year
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Item 15 Description
ATV Physical Dmg
Backhoe
Combine
Cotton Picker
Freezer
Generator
Housekeeper
Incinerator
Irrigation Equipment
Irrigation Pivot
Lawn Mower
Litter Windrower
Misc. Tools and Equipment
Skidsteer
Tractor
Tractor w Loader
Wall Cleaner
Washer/Sprayer
Well System
Other
Item 15 Make
Item 15 Value
Do You Have Any Cattle You Wish To Cover?
Yes
No
Number of Head
Value Per Head
Livestock Perils?
Basic
Broad
Page Break
Do You Wish To Add Coverage For Farm Buildings?
Yes
No
How Many Farm Buildings Do You Wish To Cover?
0
1
2
3
4
5
6
7
8
9
10
Building 1 Location?
1
2
3
4
5
6
Building 1 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Building 1 Value?
Building 1 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 1 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 1 Covered Perils?
Basic
Broad
Special
Building 1 Valuation
Replacement Cost
Actual Cash Value
Building 1 Square Footage?
Building 2 Location?
1
2
3
4
5
6
Building 2 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 2 Value?
Building 2 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 2 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 2 Covered Perils?
Basic
Broad
Special
Building 2 Valuation
Replacement Cost
Actual Cash Value
Building 2 Square Footage?
Building 3 Location?
1
2
3
4
5
6
Building 3 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 3 Value?
Building 3 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 3 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 3 Covered Perils?
Basic
Broad
Special
Building 3 Valuation
Replacement Cost
Actual Cash Value
Building 3 Square Footage?
Building 4 Location?
1
2
3
4
5
6
Building 4 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 4 Value?
Building 4 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 4 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 4 Covered Perils?
Basic
Broad
Special
Building 4 Valuation
Replacement Cost
Actual Cash Value
Building 4 Square Footage?
Building 5 Location?
1
2
3
4
5
6
Building 5 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 5 Value?
Building 5 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
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1981
1982
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1988
1989
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1991
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1998
1999
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2001
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2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 5 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 5 Covered Perils?
Basic
Broad
Special
Building 5 Valuation
Replacement Cost
Actual Cash Value
Building 5 Square Footage?
Building 6 Location?
1
2
3
4
5
6
Building 6 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 6 Value?
Building 6 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
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1965
1966
1967
1968
1969
1970
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1981
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1983
1984
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1987
1988
1989
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1991
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1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 6 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 6 Covered Perils?
Basic
Broad
Special
Building 6 Valuation
Replacement Cost
Actual Cash Value
Building 6 Square Footage?
Building 7 Location?
1
2
3
4
5
6
Building 7 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 7 Value?
Building 7 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 7 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 7 Covered Perils?
Basic
Broad
Special
Building 7 Valuation
Replacement Cost
Actual Cash Value
Building 7 Square Footage?
Building 8 Location?
1
2
3
4
5
6
Building 8 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 8 Value?
Building 8 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 8 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 8 Covered Perils?
Basic
Broad
Special
Building 8 Valuation
Replacement Cost
Actual Cash Value
Building 8 Square Footage?
Building 9 Location?
1
2
3
4
5
6
Building 9 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 9 Value?
Building 9 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 9 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 9 Covered Perils?
Basic
Broad
Special
Building 9 Valuation
Replacement Cost
Actual Cash Value
Building 9 Square Footage?
Building 10 Location?
1
2
3
4
5
6
Building 10 Type:
Barn
Breeder w Feed Bins
Brooder w Feed Bins
Broiler w Feed Bins
Pullet
Compost Shed
Dry Stack Shed
Equipment Shed
Garage
Generator Building
Litter Shed
Shop
Stable
Stack House
Turkey Confinement
Well House
Other:
Building 10 Value?
Building 10 Year Built?
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Building 10 Construction?
Frame
Masonry
Non Combustible
Fire Resistive
Building 10 Covered Perils?
Basic
Broad
Special
Building 10 Valuation
Replacement Cost
Actual Cash Value
Building 10 Square Footage?
Page Break
8
Farm Liability Limits Included In Our Coverage
$1,000,000 Per Occurrence
$2,000,000 Annual Aggregate
$1,000,000 Fire Damage Legal Liability
$5,000 Medical Payments
$1,000,000 Advertising Injury
$1,000,000 Farm Products Liability
$100,000 Employers Liability
$1,000 Employers Liability Medical Payments
Would You Like For Us To Increase The Farm Liability Coverage?
Yes
No, I Do Not Wish To Purchase Additional Coverage
If yes is selected we will offer you an optional quote at $2,000,000/$4,000,000 limits of liability.
Page Break
Is Farming Your Primary Source of Income?
Yes
No
What Are Your Gross Annual Farming Receipts?
Do You Own Any Dogs?
Yes
No
How Many Dogs and What Breed?
Do You Have A Trampoline or Pool On Your Farming Premises?
Yes
No
Is There An Airstrip on The Premises?
Yes
No
Is Any Part of The Farm Used or Leased for Organized Recreational Use?
Yes
No
Is The Property Occupied Year Round?
Yes
No
Does The Applicant Directly Supervise The Farm?
Yes
No
Are There Any Wood or Coal Fired Stoves In Any Building?
Yes
No
Is There Any Equipment Loaned or Rented to Others?
Yes
No
What Type of Year Round Water Supply Is Usable For Fire Protection?
Well
Pond/Lake
Hydrant Within 1,000 Feet
Other:
What Is The Quantity of Available Water Supply?
Less Than 1,000 Gallons
1,000 to 3,000 Gallons
Over 3,000 Gallons
Do You Manufacture, Process, Handle, Apply, or Distribute Any Products to Others For Hire or For a Fee of Any of The Following?
Dairy -Processing of Milk or Milk Products
Dairy -Sale of Raw Milk or Milk Products To The Public
Livestock (or other) Feed
Feed, Seed, Grain, Fertilizer, Chemicals, and/or Additives
Other Farm or Non Farm Products On or Off Premises
None of The Above Apply
Do Any of The Following Apply To Your Farming Operation?
Animal Boarding
Auctions or Sales
Dangerous or Exotic Animals
Events For A Charge -Parties, Weddings, or Meetings
Fishing or Hunting For A Charge
Equine Activities (Owned or Non Owned Horses)
Hay Rides
Kennels
Lodging (Bed and Breakfast) For A Charge
Real Estate Development
Recreational Activities For A Charge
Rent A Garden
Roadside Stands
Soil Sampling or Analysis Service
Tree (Christmas) Sales
U-Cut Tree Farms
U-Pick Farms
Other Non Farming Activities For A Charge
None of The Above Apply
Do You Slaughter or Butcher Livestock or Otherwise Prepare Any Products for Others and Or Sale to Others?
Yes
No
Do You Build, Repair, or Design Buildings, Equipment, or Systems For Anyone For A Charge?
Yes
No
Do You Perform Snow Removal, Tiling, Excavating or Ditching Services or Operations For A Charge?
Yes
No
Page Break
Notice of Insurance Information Practices and Fraud Statement
I agree to the
Notice of Insurance Information Practices
.
You Agree to Inform The Applicant If Coverage Is Provided The Policy Will be Issued With An Actual Cash Value Roof Endorsement. (This applies to OK property only!)
I agree to the
ACV Roof Endorsement
. Oklahoma Property Only!
You Agree to Inform The Applicant If Coverage Is Provided The Policy Will be Issued With A Cosmetic Wind and Hail Exclusion
I agree to the
Cosmetic Wind/Hail Exclusion
.
You Agree to Inform The Applicant If Coverage Is Provided The Policy Will be Issued With A Roof Damage Limitation Endorsement.(This applies to OK property only!)
I agree to the
Roof Damage Limitation Endorsement
. Oklahoma Property Only!
Agent Typed Name
Agent Signature
Clear
Using your mouse or finger, please sign your name in the box.
Date Signed
Applicant Date of Birth
Applicant Social Security Number or FEIN Number
Applicant's Typed Name
Applicant's Signature
Clear
Using your mouse or finger, please sign your name in the box.
Date of Applicant's Signature
Special Comments We Should Know About Your Risk
First Mortgage Name
First Mortgagee Address
Second Mortgagee Name
Mortgagee Address
Verification
Submit Your Application
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