What is your first name?* What is your first name?
What is your last name?* What is your last name?
What is your preferred phone number?* What is your preferred phone number?
What is your email address? What is your email address?
Occupation & Employer What is your occupation and employer name?
Please enter your date of birth. Please enter your date of birth.
MM slash DD slash YYYY
Will anyone else be named on this quote? Will anyone else be named on this quote?
Other Insured's Name Please enter their name:
Other Insured's Occupation & Employer Please enter their occupation and employer name:
Please enter their date of birth. 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) What type of farm do you have? (Please check all that apply)
How many tillable acres do you farm? How many tillable acres do you farm?
How many acres do you own? How many acres do you own?
What type(s) of animal(s) do you raise/breed? (Select all that apply) What type(s) of animal(s) do you raise/breed? (Select all that apply)
How many head of beef cattle do you have? How many head of beef cattle do you have?
What is the value of your beef cattle herd? What is the value of your beef cattle herd?
How many head of dairy cattle do you have? How many head of dairy cattle do you have?
What is the value of your dairy cattle herd? What is the value of your dairy cattle herd?
How many head of horse do you have? How many head of horse do you have?
What is the value of your horse herd? What is the value of your horse herd?
How many head of swine do you have? How many head of swine do you have?
What is the value of your swine herd? What is the value of your swine herd?
How many head of sheep do you have? How many head of sheep do you have?
What is the value of your sheep herd? What is the value of your sheep herd?
How many head of goat do you have? How many head of goat do you have?
What is the value of your goat herd? What is the value of your goat herd?
How many head of poultry/fowl do you have? How many head of poultry/fowl do you have?
What is the value of your poultry/fowl herd? What is the value of your poultry/fowl herd?
How many head of turkey/duck do you have? How many head of turkey/duck do you have?
What is the value of your turkey/duck herd? What is the value of your turkey/duck herd?
What other type(s) of animal(s) do you raise/breed? 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) 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 is the value of the "other" animal(s)?
What type of confinement operation do you have? (Select all that apply) What type of confinement operation do you have? (Select all that apply)
How many head of cow do you have? How many head of cow do you have?
Are the cows your own stock? Are the cows your own stock?
Please enter the name of the entity you are growing these cows for. Please enter the name of the entity you are growing these cows for.
How many head of swine do you have? How many head of swine do you have?
Is the swine your own stock? Is the swine your own stock?
Please enter the name of the entity you are growing swine for. Please enter the name of the entity you are growing swine for.
How many head of poultry do you have? How many head of poultry do you have?
Is the poultry your own stock? Is the poultry your own stock?
Please enter the name of the entity you are growing poultry for. Please enter the name of the entity you are growing poultry for.
Please describe the "Other" type of confinement operation you have. Please describe the "Other" type of confinement operation you have.
How many head of the "Other" animal type do you have? How many head of the "Other" animal type do you have?
Is the "Other" animal type your own stock? Is the "Other" animal type your own stock?
Please enter the name of the entity you are growing this "Other" animal type for. 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) What does your hobby farm consist of? (Select all that apply)
Please tell us what your hobby farm consists of. Please tell us what your hobby farm consists of.
Customize Your Insurance Quote Selected Quotes* 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): F Please enter the name(s) of your current insurance carrier(s), if applicable:
Farmhouse Property Address F Please enter the address of the farm.
New Purchase? F Are you in the process of purchasing this farm?
Purchase Price F What is the purchase price?
What is the closing date? F What is the closing date?
MM slash DD slash YYYY
What is the name of your farm? What is the name of your farm?
When do you need this coverage to start? F When do you need this coverage to start?
MM slash DD slash YYYY
Major Renovation F Will you renovate the farmhouse shortly after you purchase it?
Renovation Budget F What is the approximate budget for the renovation?
Renovation Time Frame F How long will the renovation take?
Occupancy F Please select the occupancy of this property.
Please describe the occupancy of this farm. F Please describe the occupancy of this farm.
Primary Home Address F Please enter your primary home address.
Previous Home Address F Please enter your previous home address.
Current Home Address F Please enter your current home address.
Will there be a mortgage? F Will there be a mortgage?
What is the name of the bank providing the mortgage? F What is the name of the bank providing the mortgage?
Who is your contact at the bank? F Who is your contact at the bank?
What is the phone number for your contact at the bank? F What is the phone number for your contact at the bank?
What is the email address for your contact at the bank? F What is the email address for your contact at the bank?
Will the insurance premium be escrowed? F Will the insurance premium be escrowed?
Is there a mortgage? F Is there a mortgage?
Please enter the bank name, if convenient. F Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. F Please enter the bank address, if convenient.
Please enter the loan number, if convenient. F Please enter the loan number, if convenient.
Is the insurance premium being escrowed? F Is the insurance premium being escrowed?
Trust or LLC F Will a legal entity, such as an LLC, own this farm?
Trust or LLC - not new purchase F 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: F Please select the type of entity that owns this farm:
Please enter the type of legal entity that owns this farm. F Please enter the type of legal entity that owns this farm.
Trust or LLC Name F Please enter the name of the legal entity.
Please list the name(s) of members/owners of this entity? F Please list the name(s) of members/owners of this entity?
Please enter the federal identification number for this farm, if available. F Please enter the federal identification number for this farm, if available.
Alarm System F Is there an alarm system in this farmhouse?
Alarm System Components F Select the components of the alarm system. (Select all that apply)
Risk Mitigation Features F Please select the risk mitigation features of this property.
Risk Mitigation Other F Please enter the other risk mitigation feature(s) in this home.
Approximate Square Footage F What is the approximate square footage of the farmhouse?
Year Built F What year was the farmhouse built? (YYYY)
How many stories does this home have? F How many stories does this home have?
What is the age of the roof? (YYYY) F What is the age of the roof? (YYYY)
Please select your roof type. F Please select your roof type.
Please provide a brief description of your roof type. F Please provide a brief description of your roof type.
Please select the construction type of your home. F Please select the construction type of your home.
Home Systems Updates F Select the features of the farmhouse that have been updated.
What other updates have been done to the farmhouse? F What other updates have been done to the farmhouse?
What year was the electrical updated? (YYYY) F What year was the electrical updated? (YYYY)
What year was the plumbing updated? (YYYY) F What year was the plumbing updated? (YYYY)
What year was the heating updated? (YYYY) F What year was the heating updated? (YYYY)
What year were the windows updated? (YYYY) F What year were the windows updated? (YYYY)
What type of foundation does your home have? F What type of foundation does your home have?
Do you have a sump pump system? F Do you have a sump pump system?
Please select the features of your sump pump system? F Please select the features of your sump pump system?
Would you like to include Sewer and Sump Pump Backup coverage in this proposal? F Would you like to include Sewer and Sump Pump Backup coverage in this proposal?
Farm Property Structures F Please select the other structures on this farm. (Select all that apply)
Other Property Structures F Enter a brief description of the other structure(s) on this farm.
Is there an attached garage? F Is there an attached garage?
Attached garage car bays? F 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) F 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? F What breed of dog do you have?
Please select the type of wood burning stove you have: F Please select the type of wood burning stove you have:
Do you keep any farm animals on this farm? F Do you keep any farm animals on this farm?
Please select the types of farm animals you own: F Please select the types of farm animals you own:
How many horses do you own? F How many horses do you own?
How many cattle do you own? F How many cattle do you own?
How many pigs do you own? F How many pigs do you own?
How many sheep do you own? F How many sheep do you own?
How many llamas do you own? F How many llamas do you own?
How many goats do you own? F How many goats do you own?
How many chickens do you own? F How many chickens do you own?
What other type(s) of farm animals do you own? F What other type(s) of farm animals do you own?
Do you care for other people's animals on your farm? F Do you care for other people's animals on your farm?
Please select the types of farm personal property you own: F Please select the types of farm personal property you own:
What other type(s) of farm personal property do you own? F What other type(s) of farm personal property do you own?
How much coverage do you need to cover your other farm personal property? F 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? F How much coverage do you need to cover your farm machinery and equipment?
How much coverage do you need to cover your livestock? F How much coverage do you need to cover your livestock?
How much coverage do you need to cover your feed? F How much coverage do you need to cover your feed?
How much coverage do you need to cover your grain? F How much coverage do you need to cover your grain?
How much coverage do you need to cover your tools? F How much coverage do you need to cover your tools?
How much coverage do you need to cover your supplies? F How much coverage do you need to cover your supplies?
Do you have an in-home business? F Do you have an in-home business? (Ie. Daycare)
Please tell us about your in-home business. F Please tell us about your in-home business.
Would you like a flood insurance proposal for your home? F Would you like a flood insurance proposal for your home?
Would you like an earthquake insurance proposal for your farm? F Would you like an earthquake insurance proposal for your farm?
Would you like to include Identity Theft Response coverage in this proposal? F 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 select the buildings you have on your farm. (Select all that apply)
Please enter the dimensions of the barn. Please enter the dimensions of the barn.
What year was the barn built? What year was the barn built?
Please select the construction type of the barn. Please select the construction type of the barn.
Is the barn fully finished? Is the barn fully finished?
Please enter the dimensions of the machine shed. Please enter the dimensions of the machine shed.
What year was the machine shed built? What year was the machine shed built?
Please select the construction type of the machine shed. Please select the construction type of the machine shed.
Is the machine shed fully finished? Is the machine shed fully finished?
Please enter the dimensions of the confinement building. Please enter the dimensions of the confinement building.
What year was the confinement building built? What year was the confinement building built?
Please select the construction type of the confinement building. Please select the construction type of the confinement building.
Is the confinement building fully finished? Is the confinement building fully finished?
Please enter the dimensions of the milking parlor. Please enter the dimensions of the milking parlor.
What year was the milking parlor built? What year was the milking parlor built?
Please select the construction type of the milking parlor. Please select the construction type of the milking parlor.
Is the milking parlor fully finished? Is the milking parlor fully finished?
Please enter the dimensions of the hay storage building. Please enter the dimensions of the hay storage building.
What year was the hay storage building built? What year was the hay storage building built?
Please select the construction type of the hay storage building. Please select the construction type of the hay storage building.
Is the hay storage building fully finished? Is the hay storage building fully finished?
Please enter the dimensions of the cold storage building. Please enter the dimensions of the cold storage building.
What year was the cold storage building built? What year was the cold storage building built?
Please select the construction type of the cold storage building. Please select the construction type of the cold storage building.
Is the cold storage building fully finished? Is the cold storage building fully finished?
Please enter the dimensions of the shop. Please enter the dimensions of the shop.
What year was the shop built? What year was the shop built?
Please select the construction type of the shop. Please select the construction type of the shop.
Is the shop fully finished? Is the shop fully finished?
Please enter the dimensions of the general livestock building. Please enter the dimensions of the general livestock building.
What year was the general livestock building built? What year was the general livestock building built?
Please select the construction type of the general livestock building. Please select the construction type of the general livestock building.
Is the general livestock building fully finished? Is the general livestock building fully finished?
Please enter the dimensions of the grain storage building. Please enter the dimensions of the grain storage building.
What year was the grain storage building built? What year was the grain storage building built?
Please select the construction type of the grain storage building. Please select the construction type of the grain storage building.
Please select the item(s) included in your grain storage system. Please select the item(s) included in your grain storage system.
Is the grain storage fully finished? Is the grain storage fully finished?
Please enter the dimensions of the stable. Please enter the dimensions of the stable.
Please enter the grain storage capacity of each of your grain storage bins. Please enter the grain storage capacity of each of your grain storage bins.
What year was the stable built? What year was the stable built?
Please select the construction type of the stable. Please select the construction type of the stable.
Is the stable fully finished? Is the stable fully finished?
Please enter the dimensions of the greenhouse. Please enter the dimensions of the greenhouse.
What year was the greenhouse built? What year was the greenhouse built?
Please select the construction type of the greenhouse. Please select the construction type of the greenhouse.
Is the greenhouse fully finished? Is the greenhouse fully finished?
Please provide a description of the "Other" farm building on your farm. Please provide a description of the "Other" farm building on your farm.
Please enter the dimensions of the "Other" farm building. Please enter the dimensions of the "Other" farm building.
What year was the "Other" farm building was built? What year was the "Other" farm building was built?
Please select the construction type of the "Other" farm building. Please select the construction type of the "Other" farm building.
Is the "Other" farm building fully finished. Is the "Other" farm building fully finished.
Farm Machinery/Equipment Please enter the total value of your farm equipment, excluding commercial trucks. F 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? Do you have a farm equipment schedule document that you can upload to us?
Please upload your farm equipment schedule. Please upload your farm equipment schedule.
Select the types of recreational vehicles you own or lease. Select the types of recreational vehicles you own or lease.
Please list any watercraft you own or lease. Please list any watercraft you own or lease.
Please list any motorcycles you own or lease. Please list any motorcycles you own or lease.
Please list any ATVs you own or lease. Please list any ATVs you own or lease.
Please list any snowmobiles you own or lease. Please list any snowmobiles you own or lease.
Please list any jet skis 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 RV/Mobile homes you own or lease.
Please list any XUVs you own or lease. Please list any XUVs you own or lease.
Please list any golf carts you own or lease. Please list any golf carts you own or lease.
Please list any any other vehicle types you own or lease. Please list any other vehicle types you own or lease.
Do you have any employees on the farm? F Do you have any employees on the farm?
How many employees do you have? F How many employees do you have?
Please select any of the following employee related coverages you would like an insurance proposal for. F Please select any of the following employee related coverages you would like an insurance proposal for.
Do any family members work on your farm? F Do any family members work on your farm?
Please list their name(s): F Please list their name(s):
Do you operate combines on your farm? F Do you operate combines on your farm?
Please select your desired coverage limit for Intake of Foreign Objects Coverage (rock ingestion). F 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? F Do you store fertilizer, seed or grain during peak season on your farm?
Please select your desired coverage limit for Peak Season coverage. F Please select your desired coverage limit for Peak Season coverage.
Do you rent or lease any equipment for your farm? F Do you rent or lease any equipment for your farm?
What is the approximate cost to rent or lease your farm equipment? F What is the approximate cost to rent or lease your farm equipment?
What are the approximate annual revenues of the farm? F 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? F 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: F Please select your desired coverage limit for Business Income/Extra Expense coverage:
Please enter your desired coverage limit for business income/extra expense coverage: F Please enter your desired coverage limit for business income/extra expense coverage:
Valuable Articles Valuables Categories Please select the types of valuable articles you would like a quote for?
Jewelry Collection Tell us about your jewelry collection.
Jewelry Appraisals? Do you have any recent appraisals for your jewelry? (3 years old or newer)
Jewelry Appraisal Upload Feel free to upload your appraisals here.
Fine Art Collection Tell us about your fine art collection.
Fine Art Appraisals? Do you have any recent appraisals for your fine art? (5 years old or newer)
Fine Art Appraisal Upload Feel free to upload your appraisals here.
Wine Collection Tell us about your wine collection.
Firearms Collection Tell us about your firearms collection.
Musical Instruments Collection Tell us about your musical instruments collection.
Antiques Collection Tell us about your antique collection.
Stamps Collection Tell us about your stamp collection.
Coin Collection Tell us about your coin collection.
Baseball Card Collection Tell us about your baseball card collection.
Fur Collection Tell us about your fur collection.
Other Collection Tell us about your other collections.
Farm Vehicles Who is the title holder of the vehicle(s)? F Who is the title holder of the vehicle(s)?
Do you do any hauling for others, for profit? F Do you do any hauling for others, for profit?
Is/Are the farm vehicle(s) stored in the off-season? F 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? F 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? F 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. F Please upload a current list of drivers, if available.
Please enter driver information for all drivers of farm vehicles. F 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: F 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: F Please enter your desired liability limit for your farm excess liability/umbrella proposal:
Please check all that apply. Please check all that apply.
Please provide a brief description of your other liability risks. Please provide a brief description of your other liability risks.
Documents and Comments Please use this field to upload any relevant insurance documents. 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. Please enter any additional remarks in the space below.
How did you hear about us? How did you hear about us?
Current customer Referred by... Google search Agency's website Email newsletter Facebook Instagram Twitter Other
Please share who referred you to us. Please share who referred you to us.
Please share what you typed into Google. Please share what you typed into Google.
Please share how you heard about us. Please share how you heard about us.
Consent* 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.
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