Insurance Farm Application

INSURANCE FARM APPLICATION

Applicant Information

Entity Type: Individual / Sole Proprietor Partnership Corporation LLC Trust

Farm Operations

Total acreage owned:    Acres operated (total):

Primary operation: Crop production Livestock Mixed Dairy Poultry

Seasonal labor employed: Yes No

Property and Structures

Building types on premises: Dwelling Barn Silo Equipment Shed Greenhouse

Farm Equipment & Machinery

Any leased equipment: Yes No

Livestock & Poultry

Cattle (head):    Average value per head:

Swine (head):    Sheep (head):    Poultry (head):

Livestock vaccination/health program in place: Yes No

Crops

List major crops, acres and estimated value at risk (up to three entries):

Insurance Coverage Requested

Policy type requested: Farmowners Commercial Property General Liability Crop Insurance Livestock Mortality

Prior Insurance and Loss History

Any losses or claims in the past five years: Yes No

Mortgagee / Loss Payee

Exclusions, Declarations and Authorization

The applicant declares that the information contained herein is true and complete to the best of the applicant's knowledge. This application will be the basis of any policy issued and the insurer may void coverage for material misrepresentation. Coverage, limits, deductible and terms are subject to the insurer's policy forms, endorsements and underwriting acceptance.

The applicant authorizes the insurer to obtain loss history, inspection reports, and other underwriting information from prior insurers, agents, and other sources. The applicant agrees to allow reasonable inspection of the premises and to provide documentation supporting values and inventory upon request. No coverage is bound unless a binder is issued in writing by the insurer or authorized representative.

The insurer may decline coverage for specific perils as defined in standard policy exclusions, including but not limited to: wear and tear, gradual deterioration, insects or vermin, infestation, dishonest acts by an insured (unless otherwise covered), war, nuclear hazard, and intentional acts. Additional exclusions may apply depending on selected coverages.

Certification

By signing below, the applicant certifies under penalty of law that all statements and representations contained in this application are true and complete. The applicant understands that failure to disclose material facts or submission of false information may result in denial of coverage and rescission or cancellation of any policy issued. The applicant further authorizes release of information necessary to underwrite and service the policy, including claims handling and subrogation.

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