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Farm Risk Evaluation
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What is your first name?
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What is your first name? *
What is your last name?
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What is your last name? *
What is your email address?
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What is your email address? *
What is your preferred phone number?
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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?
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?
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?
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?
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?
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?
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?
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?
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?
Are you interested in Water-Sewer Backup Coverage?
Yes
No
Do you have an alarm system?
Do you have an alarm system?
Yes
No
Do you have a second home?
Do you have a second home?
Yes
No
Do you own any ATV's, snowmobiles, XUV's, boats, golf carts?
Do you own any ATV's, snowmobiles, XUV's, boats, golf carts?
Yes
No
Select the liability exposures you have below:
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)
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?
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)
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?
What other types of farm animals do you own?
How many horses do you own?
How many horses do you own?
How many cattle do you own?
How many cattle do you own?
How many pigs do you own?
How many pigs do you own?
How many sheep do you own?
How many sheep do you own?
How many of the "other" type of animal 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?
Is care, custody and control coverage required for these farm animals?
Yes
No
Are you interested in flood insurance?
Are you interested in flood insurance?
Yes
No
Are you interested in earthquake insurance?
Are you interested in earthquake insurance?
Yes
No
Are you interested in Identity Theft Response Coverage?
Are you interested in Identity Theft Response Coverage?
Yes
No
Are the farm personal property limits adequate for what you own?
Are the farm personal property limits adequate for what you own?
Yes
No
Is the farm inventory sheet completed and signed?
Is the farm inventory sheet completed and signed?
Yes
No
Are the farm building limits adequate?
Are the farm building limits adequate?
Yes
No
Do you have employees on the farm?
Do you have employees on the farm?
Yes
No
How many employees do you have?
How many employees do you have?
Who are the members of the corporation?
Who are the members of the corporation?
First Name
Last Name
Role
Documents and Comments
Uploaded Documents
Please use this field to upload any other relevant information for this new residence. (i.e. mortgage requirements, elevation certificates, wind mitigation form, etc.).
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Max. file size: 128 MB.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
Consent
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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.
I agree
Gates Skene
601-968-0256
https://www.rossandyerger.com/private-client-group
gskene@rossandyerger.com
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