if yes list carrier, and # of years. If none type
N/C
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Is there a year-round water supply usable for fire protection?
1. DOES THE APPLICANT HAVE ANY OTHER BUSINESS OR OTHER NON-FARM ACTIVITIES ON OR OFF THE
PREMISES, SUCH AS DUDE RANCH, BED & BREAKFAST OR RESORT FACILITY?
2. IS FARMING THE PRIMARY SOURCE OF THE INSURED'S INCOME?
4. HAS ANY POOLICY BEEN CANCELLED OR NON-RENEWED IN THE PAST 5 YEARS?
5. HAVE YOU INSPECTED THIS PROPERTY IN THE LAST (12) MONTHS?
6. DURING THE LAST 5 YEARS HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY
DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN
CONNECTION WITH THIS OR ANY OTHER PROPERTY?
7. ARE INDEPENDENT CONTRACTORS HIRED TO PREFORM ANY FARMING OPERATIONS?
8. IS ANY PART OF THE FARM RENTED OR LEASED FOR RECREATIONAL USE?
9. ARE THE FARM PREMISES OPEN TO THE PUBLIC FOR ACTIVITIES SUCH AS ROADSIDE STANDS,
U-PICK, RECREATIONAL, CAMPING, RENT-A-GARDEN, AUCTION, SALES, SHOWS, RODEOS, HAY RIDES,
FISHING,KENNELS, ANIMAL BOARDING, OR CHRISTMAS TREE SALES?
10. ARE ANY PORTIONS OF THE FARM OR STRUCTURES RENTED OR LEASED OR USED BY ANY OTHER
INDIVIDUAL, CORPERATION OR INTREST FOR OTHER THAN FARMING?
11. DOES THE APPLICANT OR SPOUSE OWN, RENT OR OPERATE AS A FARM, RANCH OR RESIDENCE ANY
PREMISES OTHER THAN THOSE DESCRIBED IN THE PREMISES INFORMATION SECTION?
12. IS ANY LAND HELD FOR REAL ESTATE DEVELOPMENT OR SPECULATION?
13. DOES APPLICANT MAINTAIN ANY VACTION OR SEASONAL PREMISES?
15. DOES APPLICANT MAINTAIN ANY VACTION OR SEASONAL PREMISES?
16. DOES THE INSURED PLAN ANY CONSTRUCTION OR RENOVATION WORK TO BE DONE ON THE  
PREMISES IN THE NEXT 12 MONTHS?
18. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN
DURING THE PAST FIVE YEARS?
BODILY INJURY AND PROPERTY DAMAGE LIABILITY:
PERSONAL AND ADVERTISING INJURY LIABILITY:
PROPERTY DAMAGE LIABILITY FIRE DAMAGE LIMIT:
ADDITIONAL COVERAGE - DAMAGE TO PROPERTY
OF OTHERS:
ADDITIONAL
INTEREST/CERTIFICATE RECIPIENT:
PLEASE LIST BELOW ALL OF THE
INFORMATION OF THE LIEN HOLDER(S) OF ANY
AND ALL PROPERTY(S) TO BE INSURED
1. DOES APPLICANT BUILD, REPAIR OR DESIGN MACHINERY, EQUIPMENT OR SYSTEMS FOR ANYONE AT
A CHARGE ?
2. DOES APPLICANT RENT OR LEASE EQUIPMENT TO OTHERS ?
3. DOES ANY MACHINERY OR EQUIPMENT OWNED OR OPPERATED BY THE APPLICANT NOT CONFORM
TO APPLICABLE SAFETY REGULATIONS ?
4. DOES APPLICANT MIX, PROCESS, SLAUGHTER, BUTCHER OR OTHERWISE PREPARE FOR ANY "END
CONSUMER" HIS OR ANY OTHER GROWER'S PRODUCT ?
5. DOES APPLICANT HANDLE ANY PRODUCT, SUCH AS SEED, FERTILIZER, SPRAYS, ETC. FOR RESALE ?
6. ARE ANY CONTRACT OR SERVICE OPERATIONS PREFORMED FOR OTHERS SUCH AS ,SNOW REMOVAL,
TILING, FIELD/DRAIN TILE EXCAVATING, OR DITCHING ?
7. ARE THERE ANY UNUSUAL HAZARDS SUCH AS ( BUT NOT LIMITED TO ) OPEN DUMP PITS, SUMP
HOLES, PONDS, LAKES, OR RESERVOIRS ?
9. ARE ANY " HOLD HARMLESS" OR "INDEMNIFYING" AGREEMENTS IN EFFECT ?
15. DOES APPLICANT SERVE ON ANY BOARDS FOR REMUNERATION ?
17. DOES APPLICANT HAVE ANY POTENTIALLY DANGEROUS ANIMAL OR EXOTIC PETS ?
18. ARE ANY LIVESTOCK PRESENT ON THE PREMISES, OR ANTICIPATED DURING THE YEAR ?
20. ARE LIVESTOCK NEAR ANY PUBLIC ROAD OR HIGHWAY ?
21. DOES INSURED OWN, BOARD, RACE, BREED, OR RENT HORSES ?
23. IF CATTLE ARE PRESENT ON PREMISES DO YOU NOW OR HAVE IN THE PAST SUPPLEMENTED
CATTLE FEES WITH BONE MEAL, PROTIEN SUPPLEMENTS OR ANIMAL BY-PRODUCTS ?
26. ARE THERE ANY RETAIL SALES OF MILK PRODUCTS TO THR PUBLIC ?
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING
INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS
OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT
AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED
INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO
THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP
DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY
USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO
REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY
INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH
INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON
HOW TO SUBMIT A REQUEST TO US.
Your Personal Data
Name:
Address:
City:
State:
County:
Zip Code:
E Mail:
Retype E Mail:
Phone:
Fax:
Currently Insured:
Marital Status:
Home Owner:
Effective Date:
How many years of Farming Experience?
Type of Farm
Type of Farm Operations ( Check all that apply )
AQUACULTURE
 FLOWERS
 HOBBY / GENTLEMAN FARM
 LIVESTOCK GRAZING
COTTON
 FRUIT / CITRUS
 LIVESTOCK FEEDLOT
 LIVESTOCK PROCESSING
DAIRY
 FIELD CROPS
 LIVESTOCK CONFINEMENT
 FUR BEARING ANIMALS
HORSES
 POULTRY
 GREENHOUSES
 VINEYARDS
NUTS
 VEGETABLES
 TOBACCO
 NURSERY STOCK
Prior Insurance Information
Prior Carrier:
 Type of Insurance:
Amount of Coverage:
 Policy #:
Location / Sublocation(s)
County
 Section
Location#1 Address:
Township
Location#1 Type:
Farm Name
 # of acres
Source:
 Quantity:
 Distance to Hydrant? ft.
Fire District Code:
 Operated by:
 Distance to Fire Station? mi.
Owned by Applicant:
 Fire District Name:
Location # 2 if N/A Leave Blank:
Is there a year-round water supply usable for fire protection?
Location # 2 Address:
 County
 Section
Location # 2 Type:
 Farm Name
 # of acres
 Township
Source:
 Quantity:
 Distance to Hydrant? ft.
Fire District Code:
 Operated by:
 Distance to Fire Station? mi.
Owned by Applicant:
 Fire District Name:
Location # 3 if N/A Leave Blank:
Is there a year-round water supply usable for fire protection?
Location # 3 Address:
 County
 Section
Location # 3 Type:
 Farm Name
 # of acres
 Township
Source:
 Quantity:
 Distance to Hydrant? ft.
Fire District Code:
 Operated by:
 Distance to Fire Station? mi.
Owned by Applicant:
 Fire District Name:
Location # 4 if N/A Leave Blank:
Is there a year-round water supply usable for fire protection?
Location # 4 Address:
 County
 Section
Location # 4 Type:
 Farm Name
 # of acres
 Township
Source:
 Quantity:
 Distance to Hydrant? ft.
Fire District Code:
 Operated by:
 Distance to Fire Station? mi.
Owned by Applicant:
 Fire District Name:
Location # 5 if N/A Leave Blank:
Is there a year-round water supply usable for fire protection?
Location # 5 Address:
 County
 Section
Location # 5 Type:
 Farm Name
 # of acres
 Township
Source:
 Quantity:
 Distance to Hydrant? ft.
Fire District Code:
 Operated by:
 Distance to Fire Station? mi.
Owned by Applicant:
 Fire District Name:
3. IS THIS BUSINESS NEW TO THE AGENCY?
14. IS THE APPLICANT A SUBSIDIARY OF ANOTHER?
17. IS A FORMAL SAFETY PROGRAM IN EXISTENCE?
AGRICULTURE LIABILITY SECTION:
FARM COMMERCIAL LIABILITY:
FARM PERSONAL LIABILITY:
MEDICAL PAYMENTS:
General Information:
8. IS THERE AN AIRSTIP ON THE PREMISES ?
10. IS THERE A SWIMMING POOL ON THE PREMISES ?
TYPE:
 FENCED:
 DIVING BOARD:
 SLIDE:
 DEPTH:
 FEET ?
11. IS THER ANY WATERCRAFT EXPOSURE ?
12. IS THER ANY SNOWMOBILE EXPOSURE ?
13. IS THER ANY DIRT BIKE EXPOSURE ?
14. IS THERE A TRAMPOLINE ON THE PREMISES ?
16. ARE PREMISES USED BY OTHERS FOR HUNTING, FISHING OR OTHER RECREATIONAL ACTIVITIES ?
LIVESTOCK / DAIRY:
19. ARE LIVESTOCK KEPT IN AREAS THAT ARE NOT ADEQUATLEY FENCED AND MAINTAINED IN
A GOOD STATE OF REPAIR ?
22. ANY NON-OWNED HORSES ON INSURED PREMISES ?
24. NUMBER OF ANIMALS MILKED ?
25. IS THERE ANY PROCESSING OF MILK ?
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