Farm Ranch Quote Form Star H Equine Insurance

Farm/Ranch Insurance Quote Information

Full Name:

Farm Name:

Mailing Address:

Property Address (If different):

Home Ph:    Cell:

Work Ph:    Fax:

Email:

Website:

Name of Closest Fire Depart:    Distance From Property:

Is there a fire hydrant within 1000 ft of property? YES NO

County Property is In:    # of Acres:

DWELLINGS:

1) Main Dwelling:

Year Built:    Year Updated and Updates:

Square Footage:    Est. Replacement Cost:

Type of Exterior Construction:    Type of Roof:

Age of Roof:

Type of Heating System:    Age of Heating System:

Type of Cooling System:    Age of Cooling System:

Is there a Central Station Alarm?   or Local Alarm?

Are there Smoke Alarms?    Wired or Battery:

1) Other Dwelling:

Year Built:    Year Updated and Updates:

Square Footage:    Est. Replacement Cost:

Type of Exterior Construction:    Type of Roof:

Age of Roof:

Type of Heating System:    Age of Heating System:

Type of Cooling System:    Age of Cooling System:

Is there a Central Station Alarm?   or Local Alarm?

Are there Smoke Alarms?    Wired or Battery:

If any dwelling is over 25 years old, please indicate when plumbing, heating/AC and wiring were updated:

Is there a Mortgage on Property?

Mortgage Company:

Is your Premium Paid through your Mortgage Escrow? or Self?

How Long Have You Been at this Location?

FARM BUILDINGS:

Building #1:

Use:    Year Built:

Square Footage:    Est. Replacement Cost $:

Exterior Construction:    Wood Trusses or Steel Trusses:

Roof Material:    Age of Roof:

Smoke Alarm:    Wired or Battery:    Lightning Rods:

Fully Enclosed:    Any Improvements/Yr?

# of Stalls:    Size of Stalls:

Building #2:

Use:    Year Built:

Square Footage:    Est. Replacement Cost $:

Exterior Construction:    Wood Trusses or Steel Trusses:

Roof Material:    Age of Roof:

Smoke Alarm:    Wired or Battery:    Lightning Rods:

Fully Enclosed:    Any Improvements/Yr?

# of Stalls:    Size of Stalls:

Building #3:

Use:    Year Built:

Square Footage:    Est. Replacement Cost $:

Exterior Construction:    Wood Trusses or Steel Trusses:

Roof Material:    Age of Roof:

Smoke Alarm:    Wired or Battery:    Lightning Rods:

Fully Enclosed:    Any Improvements/Yr?

# of Stalls:    Size of Stalls:

Building #4:

Use:    Year Built:

Square Footage:    Est. Replacement Cost $:

Exterior Construction:    Wood Trusses or Steel Trusses:

Roof Material:    Age of Roof:

Smoke Alarm:    Wired or Battery:    Lightning Rods:

Fully Enclosed:    Any Improvements/Yr?

# of Stalls:    Size of Stalls:

(please copy this page if there are additional buildings to list more buildings)

QUESTIONS:

Do you operate any other type of business from your farm property?

Brief Description:

Do you own or operate any additional farm properties, or own a seasonal property such as a vacation home?

Swimming Pool:    Enclosed by a Fence:

Diving Board:    Slide:

Trampoline:

Dogs:    # and Type:

Personal Items: Do you have any personal items to schedule? (jewelry, guns, coins, anything of high value). Please attach a list with description, current value.

Farm Machinery and Equipment: Make, Model, Value:

Tack and Equipment Value: $

HORSE OPERATION:

1) How many horses do you Personally Own/Lease?

Indicate #/Use:

Show/Pleasure:    How many taken off premise at one time?

Breeding: Stallions:    Stud Fee:    Mares:

Foals / Yearlings:

Lesson Horses:    How many taken off premise at one time?

Other:

Types of Horses/ Uses:

NON-OWNED HORSES / LESSONS / ACTIVITIES:

2) How many NON-OWNED horses are normally on your property:

Boarding:    Normal Monthly Boarding Charge:

Training:    Normal Monthly Training Charge:

Breeding:    Typical annual breeding receipts:

Other:

3) Non-Owned Horse Values: (of horses on your property)

Minimum Value:    Average Value:    Maximum Value:

4) Where are horses kept at night? Barn or pasture:

5) What type of Fencing do you have:

4) How many years experience do you have caring for horses:

LESSONS / CLINICS / DAY CAMPS / HORSE OPERATION ACTIVITIES:

1) Do you give Riding Lessons?    # per week:    Charge/Lesson $

# of lessons on Client’s horses per week:

# of lessons on school horses per week:

Who Gives Lessons: Self:    How many years experience teaching:

Independent Instructor: Names:

Does Ind. Instructor have their own insurance?

Lessons: English:    Western:    Jumping:    other:

What Safety Gear is Required:

2) Do you hold Clinics on you property:    How Many:

Average # of participants:    # Spectators:

Gross Receipts: $

3) Do you have Day Camps:    # of Days:    Minimum Age:

Describe Activities:

Gross Receipts: $

4) Do you have Horse Shows:    # of Days:

Avg # Participants:    # Spectators:

Gross Receipts: $

Concession Stand?    Gross Receipts $

5) Do you Sell Horses?    # per year:    Gross Receipts:

6) Do you Sell Tack and Clothing?    Gross Receipts:

7) Do you Trailer horses for other people?    # Horses per Trip:

Mileage Radius Per Trip:    Average # Trips Per Year:

Trailer: (Type and capacity):

8) Are there any other equine activities on your property not mentioned above (pony parties, etc)

9) How many years experience do have owning horses:

EMPLOYEES / INDEPENDENT CONTRACTORS:

How many Employees or Independent Contractors do you have?

Full Time:    Annual Payroll:

Part Time:    Annual Payroll:

Who cares for the horses/farm when you are out of town?

CURRENT INSURANCE:

with:

Current Premium: $    Renewal Date:

Have you been “Cancelled” or “Non-Renewed” by an insurance company in the last three years (and why)?

Have you had any claims or losses in the past three years?

Describe losses with date, type of claim, and approximate amount paid:

Please fax back to 336-940-5475, or sign, scan and email.

FQ 10.12