Farm Intake Form
Name
First
Last
Email
Phone
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
FEIN#
BUSINESS TYPE
INDIVIDUAL
PARTNERSHIP
CORPORATION
JOINT VENTURE
SUBCHAPTER *S* CORPORATION
NOT FOR PROFIT ORG
LLC
TYPE OF FARM / RANCH OPERATIONS
AQUACULTURE
COTTON
DAIRY
FIELD CROPS
FLOWERS
FRUIT / CITRUS
FUR BEARING ANIMALS
GREENHOUSES
HOBBY / GENTLEMAN FARM
HORSES
LIVESTOCK CONFINEMENT
LIVESTOCK FEEDLOT
LIVESTOCK GRAZING
LIVESTOCK PROCESSING
NURSERY STOCK
NUTS
POULTRY
TOBACCO
VEGETABLES
VINEYARDS
DESCRIBE FARM/RANCH OPERATIONS AND ANY INCIDENTAL BUSINESS ACTIVITIES. DESCRIBE ADDITIONAL ITEMS IN OPTIONAL CHECK BOXES.
LOSS HISTORY
ENTER ALL CLAIMS OR OCCURRENCES FOR THE PAST FIVE YEARS
DATE OF OCCURRENCE
Add
Remove
TYPE OF LOSS
Add
Remove
DESCRIPTION OF OCCURRENCE
Add
Remove
AMOUNT PAID
Add
Remove
PRIOR INSURANCE INFORMATION
PRIOR CARRIER
Add
Remove
TYPE OF INSURANCE
Add
Remove
POLICY #
Add
Remove
DATE OF OCCURRENCE
Add
Remove
OTHER RELATED POLICIES
INSURED NAME
Add
Remove
TYPE OF INSURANCE
Add
Remove
POLICY #
Add
Remove
PREMISES INFORMATION
LOC #
COUNTY
SECTION
TOWNSHIP
FARM NAME
# ACRES
IS THERE A YEAR-ROUND WATER SUPPLY USABLE FOR FIRE PROTECTION?
YES
NO
IF YES, (A) SOURCE =
WELL
POND / LAKE
HYDRANT
QUANTITY
LESS THAN 1,000 GALLONS
1,000-3,000 GALLONS
OVER 3,000 GALLONS
PROT CLASS
FIRE DISTRICT CODE
FIRE DISTRICT NAME
OPERATED BY
APPLICANT
TENANT
OWNED BY APPLICANT
YES
NO
DISTANCE TO PUBLIC HYDRANT
FT
DISTANCE TO FIRE STATION
MI
GENERAL INFORMATION
DOES APPLICANT HAVE ANY OTHER BUSINESS OR OTHER NON-FARM ACTIVITIES ON OR OFF PREMISES, SUCH AS DUDE RANCH, BED & BREAKFAST OR RESORT FACILITY?
YES
NO
IF SO, INCLUDE RECEIPTS: $
EXPLAIN ALL "YES" RESPONSES
IS FARMING THE PRIMARY SOURCE OF THE INSURED'S INCOME?
YES
NO
EXPLAIN ALL "YES" RESPONSES
IS THIS BUSINESS NEW TO THE AGENCY?
YES
NO
EXPLAIN ALL "YES" RESPONSES
HAS ANY POLICY BEEN CANCELLED OR NONRENEWED IN THE PAST FIVE (5) YEARS?
YES
NO
(Missouri Applicants - Do not answer this question)
EXPLAIN ALL "YES" RESPONSES
HAVE YOU INSPECTED THIS PROPERTY IN THE LAST TWELVE (12) MONTHS?
YES
NO
EXPLAIN ALL "YES" RESPONSES
DURING THE LAST FIVE YEARS (TEN IN RI), 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?
YES
NO
(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
EXPLAIN ALL "YES" RESPONSES
ARE INDEPENDENT CONTRACTORS HIRED TO PERFORM ANY FARMING OPERATIONS?
YES
NO
EXPLAIN ALL "YES" RESPONSES
IS ANY PART OF THE FARM RENTED OR LEASED FOR RECREATIONAL USE?
YES
NO
EXPLAIN ALL "YES" RESPONSES
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?
YES
NO
EXPLAIN ALL "YES" RESPONSES
ARE ANY PORTIONS OF THE FARM OR STRUCTURES RENTED OR LEASED OR USED BY ANY OTHER INDIVIDUAL, CORPORATION OR INTEREST FOR OTHER THAN FARMING?
YES
NO
EXPLAIN ALL "YES" RESPONSES
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?
YES
NO
EXPLAIN ALL "YES" RESPONSES
IS ANY LAND HELD FOR REAL ESTATE DEVELOPMENT OR SPECULATION?
YES
NO
EXPLAIN ALL "YES" RESPONSES
DOES APPLICANT MAINTAIN ANY VACATION OR SEASONAL PREMISES?
YES
NO
EXPLAIN ALL "YES" RESPONSES
IS THE APPLICANT A SUBSIDIARY OF ANOTHER?
YES
NO
EXPLAIN ALL "YES" RESPONSES
DOES THE APPLICANT HAVE SUBSIDIARIES?
YES
NO
EXPLAIN ALL "YES" RESPONSES
DOES THE INSURED PLAN ANY CONSTRUCTION OR RENOVATION WORK TO BE DONE ON THE PREMISES IN THE NEXT TWELVE (12) MONTHS?
YES
NO
EXPLAIN ALL "YES" RESPONSES
IS A FORMAL SAFETY PROGRAM IN EXISTENCE?
YES
NO
EXPLAIN ALL "YES" RESPONSES
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS?
YES
NO
EXPLAIN ALL "YES" RESPONSES
Business Name
Is farm location different than mailing address?
Yes
No
Farm Location
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Farming Operation Description
# of acres – amount owned / leased / leased to others
% Farmed
# of years farming
# of FT / PT Employees
Total payroll
Total revenue
Is farming your main source of income?
Yes
No
Farm Dwelling / Primary Dwelling
Size
Wiring · Construct
Year of construction
Heating
Additional farm dwellings?
Occupancy?
Outbuildings and other structures
Livestock?
Farm implements / equipment?
# of autos
Vehicles used for anything other than insured’s farming ops?
Yes
No
Additional drivers
First Name
Last Name
Add
Remove
Scroll to top
Scroll to top
