What is your first name?
What is your last name?
What is your preferred phone number?
What is your email address?
What is your occupation and employer name?
Please enter your date of birth.
MM slash DD slash YYYY
Will anyone else be named on this quote?
Please enter their name:
Please enter their occupation and employer name:
Please enter their date of birth.
MM slash DD slash YYYY
Farm Type
What type of farm do you have? (Please check all that apply)
How many tillable acres do you farm?
How many acres do you own?
What type(s) of animal(s) do you raise/breed? (Select all that apply)
How many head of beef cattle do you have?
What is the value of your beef cattle herd?
How many head of dairy cattle do you have?
What is the value of your dairy cattle herd?
How many head of horse do you have?
What is the value of your horse herd?
How many head of swine do you have?
What is the value of your swine herd?
How many head of sheep do you have?
What is the value of your sheep herd?
How many head of goat do you have?
What is the value of your goat herd?
How many head of poultry/fowl do you have?
What is the value of your poultry/fowl herd?
How many head of turkey/duck do you have?
What is the value of your turkey/duck herd?
What other type(s) of animal(s) do you raise/breed?
How many head of "other" type(s) of animal(s) do you have? (Please state values below)
What is the value of the "other" animal(s)?
What type of confinement operation do you have? (Select all that apply)
How many head of cow do you have?
Are the cows your own stock?
Please enter the name of the entity you are growing these cows for.
How many head of swine do you have?
Is the swine your own stock?
Please enter the name of the entity you are growing swine for.
How many head of poultry do you have?
Is the poultry your own stock?
Please enter the name of the entity you are growing poultry for.
Please describe the "Other" type of confinement operation you have.
How many head of the "Other" animal type do you have?
Is the "Other" animal type your own stock?
Please enter the name of the entity you are growing this "Other" animal type for.
What does your hobby farm consist of? (Select all that apply)
Please tell us what your hobby farm consists of.
Customize Your Insurance Quote
You have the ability to customize this form by unchecking the boxes next to the coverages you do not wish to receive quotes for.
Please enter the name(s) of your current insurance carrier(s), if applicable:
Farmhouse
Please enter the address of the farm.
Are you in the process of purchasing this farm?
What is the purchase price?
What is the closing date?
MM slash DD slash YYYY
What is the name of your farm?
When do you need this coverage to start?
MM slash DD slash YYYY
Will you renovate the farmhouse shortly after you purchase it?
What is the approximate budget for the renovation?
How long will the renovation take?
Please select the occupancy of this property.
Please describe the occupancy of this farm.
Please enter your primary home address.
Please enter your previous home address.
Please enter your current home address.
Will there be a mortgage?
What is the name of the bank providing the mortgage?
Who is your contact at the bank?
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank?
Will the insurance premium be escrowed?
Is there a mortgage?
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient.
Please enter the loan number, if convenient.
Is the insurance premium being escrowed?
Will a legal entity, such as an LLC, own this farm?
Is there a legal entity, such as an LLC, involved in the ownership of this farm?
Please select the type of entity that owns this farm:
Please enter the type of legal entity that owns this farm.
Please enter the name of the legal entity.
Please list the name(s) of members/owners of this entity?
Please enter the federal identification number for this farm, if available.
Is there an alarm system in this farmhouse?
Select the components of the alarm system. (Select all that apply)
Please select the risk mitigation features of this property.
Please enter the other risk mitigation feature(s) in this home.
What is the approximate square footage of the farmhouse?
What year was the farmhouse built? (YYYY)
How many stories does this home have?
What is the age of the roof? (YYYY)
Please select your roof type.
Please provide a brief description of your roof type.
Please select the construction type of your home.
Select the features of the farmhouse that have been updated.
What other updates have been done to the farmhouse?
What year was the electrical updated? (YYYY)
What year was the plumbing updated? (YYYY)
What year was the heating updated? (YYYY)
What year were the windows updated? (YYYY)
What type of foundation does your home have?
Do you have a sump pump system?
Please select the features of your sump pump system?
Would you like to include Sewer and Sump Pump Backup coverage in this proposal?
Please select the other structures on this farm. (Select all that apply)
Enter a brief description of the other structure(s) on this farm.
Is there an attached garage?
How many car bays does the attached garage have?
Please select the items below that are present or will be present at this home. (Select all that apply)
What breed of dog do you have?
Please select the type of wood burning stove you have:
Do you keep any farm animals on this farm?
Please select the types of farm animals you own:
How many horses do you own?
How many cattle do you own?
How many pigs do you own?
How many sheep do you own?
How many llamas do you own?
How many goats do you own?
How many chickens do you own?
What other type(s) of farm animals do you own?
Do you care for other people's animals on your farm?
Please select the types of farm personal property you own:
What other type(s) of farm personal property do you own?
How much coverage do you need to cover your other farm personal property?
How much coverage do you need to cover your farm machinery and equipment?
How much coverage do you need to cover your livestock?
How much coverage do you need to cover your feed?
How much coverage do you need to cover your grain?
How much coverage do you need to cover your tools?
How much coverage do you need to cover your supplies?
Do you have an in-home business? (Ie. Daycare)
Please tell us about your in-home business.
Would you like a flood insurance proposal for your home?
Would you like an earthquake insurance proposal for your farm?
Would you like to include Identity Theft Response coverage in this proposal?
Farm Buildings
Please select the buildings you have on your farm. (Select all that apply)
Please enter the dimensions of the barn.
What year was the barn built?
Please select the construction type of the barn.
Is the barn fully finished?
Please enter the dimensions of the machine shed.
What year was the machine shed built?
Please select the construction type of the machine shed.
Is the machine shed fully finished?
Please enter the dimensions of the confinement building.
What year was the confinement building built?
Please select the construction type of the confinement building.
Is the confinement building fully finished?
Please enter the dimensions of the milking parlor.
What year was the milking parlor built?
Please select the construction type of the milking parlor.
Is the milking parlor fully finished?
Please enter the dimensions of the hay storage building.
What year was the hay storage building built?
Please select the construction type of the hay storage building.
Is the hay storage building fully finished?
Please enter the dimensions of the cold storage building.
What year was the cold storage building built?
Please select the construction type of the cold storage building.
Is the cold storage building fully finished?
Please enter the dimensions of the shop.
What year was the shop built?
Please select the construction type of the shop.
Is the shop fully finished?
Please enter the dimensions of the general livestock building.
What year was the general livestock building built?
Please select the construction type of the general livestock building.
Is the general livestock building fully finished?
Please enter the dimensions of the grain storage building.
What year was the grain storage building built?
Please select the construction type of the grain storage building.
Please select the item(s) included in your grain storage system.
Is the grain storage fully finished?
Please enter the dimensions of the stable.
Please enter the grain storage capacity of each of your grain storage bins.
What year was the stable built?
Please select the construction type of the stable.
Is the stable fully finished?
Please enter the dimensions of the greenhouse.
What year was the greenhouse built?
Please select the construction type of the greenhouse.
Is the greenhouse fully finished?
Please provide a description of the "Other" farm building on your farm.
Please enter the dimensions of the "Other" farm building.
What year was the "Other" farm building was built?
Please select the construction type of the "Other" farm building.
Is the "Other" farm building fully finished.
Farm Machinery/Equipment
Please enter the total value of your farm equipment, excluding commercial trucks.
Do you have a farm equipment schedule document that you can upload to us?
Please upload your farm equipment schedule.
Select the types of recreational vehicles you own or lease.
Please list any watercraft you own or lease.
Please list any motorcycles you own or lease.
Please list any ATVs you own or lease.
Please list any snowmobiles you own or lease.
Please list any jet skis you own or lease.
Please list any RV/Mobile homes you own or lease.
Please list any XUVs you own or lease.
Please list any golf carts you own or lease.
Please list any other vehicle types you own or lease.
Do you have any employees on the farm?
How many employees do you have?
Please select any of the following employee related coverages you would like an insurance proposal for.
Do any family members work on your farm?
Please list their name(s):
Do you operate combines on your farm?
Please select your desired coverage limit for Intake of Foreign Objects Coverage (rock ingestion).
Do you store fertilizer, seed or grain during peak season on your farm?
Please select your desired coverage limit for Peak Season coverage.
Do you rent or lease any equipment for your farm?
What is the approximate cost to rent or lease your farm equipment?
What are the approximate annual revenues of the farm?
Would you like coverage to cover payroll and other expenses you would continue to incur after a loss? (Ie. Business Income/Extra Expense Coverage)
Please select your desired coverage limit for Business Income/Extra Expense coverage:
Please enter your desired coverage limit for business income/extra expense coverage:
Valuable Articles
Please select the types of valuable articles you would like a quote for?
Tell us about your jewelry collection.
Do you have any recent appraisals for your jewelry? (3 years old or newer)
Feel free to upload your appraisals here.
Tell us about your fine art collection.
Do you have any recent appraisals for your fine art? (5 years old or newer)
Feel free to upload your appraisals here.
Tell us about your wine collection.
Tell us about your firearms collection.
Tell us about your musical instruments collection.
Tell us about your antique collection.
Tell us about your stamp collection.
Tell us about your coin collection.
Tell us about your baseball card collection.
Tell us about your fur collection.
Tell us about your other collections.
Farm Vehicles
Who is the title holder of the vehicle(s)?
Do you do any hauling for others, for profit?
Is/Are the farm vehicle(s) stored in the off-season?
Do you currently carry insurance coverage that meets the minimum requirements of a farm excess liability/umbrella policy?
Do you have a completed list of drivers with license number(s) and date(s) of birth that you can upload to us?
Please upload a current list of drivers, if available.
Please enter driver information for all drivers of farm vehicles.
Farm Excess Liability / Umbrella
Please select the liability limit(s) you would like a farm excess liability/umbrella proposal for:
Please enter your desired liability limit for your farm excess liability/umbrella proposal:
Please check all that apply.
Please provide a brief description of your other liability risks.
Documents and Comments
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, Equipment schedule, etc...)
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
