Farm Risk Evaluation

What is your first name?*

What is your first name? *

What is your last name?*

What is your last name? *

What is your email address?*

What is your email address? *

What is your preferred phone number?*

What is your preferred phone number? *

Farm Coverage Questionnaire

Do you want to schedule/cover any collectibles such as antiques, fine art, stamps, coins, or baseball cards?

Yes
No

Do you want to schedule/cover any valuable jewelry or furs?

Yes
No

Do you want to schedule/cover any costly sporting equipment such as golf clubs or firearms?

Yes
No

Do you want to schedule/cover any costly sporting equipment such as golf clubs or firearms?

Yes
No

Do you baby sit in your home?

Yes
No

Have you made recent remodeling changes to your home in excess of $5,000 that we may not be aware of?

Yes
No

Do you have a finished basement?

Yes
No

Do you have a battery backup system, secondary sump pump, or exterior sump pump to help protect your basement?

Yes
No
Not Applicable

Are you interested in Water-Sewer Backup Coverage?

Yes
No

Do you have an alarm system?

Yes
No

Do you have a second home?

Yes
No

Do you own any ATV's, snowmobiles, XUV's, boats, golf carts?

Yes
No

Select the liability exposures you have below:

Swimming pool
Pond
Trampoline
None

What is the total amount of assets that need to be covered by farm umbrella? (Enter desired limit)

Do you own a dog, cat, or other animal that could bite someone and cause a lawsuit?

Yes
No

Select the types of farm animals you own: (Select all that apply)

Horses
Cattle
Pigs
Sheep
Other
None

What other types of farm animals do 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 of the "other" type of animal do you own?

Is care, custody and control coverage required for these farm animals?

Yes
No

Are you interested in flood insurance?

Yes
No

Are you interested in earthquake insurance?

Yes
No

Are you interested in Identity Theft Response Coverage?

Yes
No

Are the farm personal property limits adequate for what you own?

Yes
No

Is the farm inventory sheet completed and signed?

Yes
No

Are the farm building limits adequate?

Yes
No

Do you have employees on the farm?

Yes
No

How many employees do you have?

Who are the members of the corporation?

First Name	Last Name	Role

Documents and Comments

Uploaded Documents

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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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Farm Coverage Questionnaire

Documents and Comments

Marcella Pitt

RiskRevu^TM Newsletter

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Farm Risk Evaluation

Farm Coverage Questionnaire

Documents and Comments

Marcella Pitt

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter