Name*

Address*

City*         State*         Zip*  

Phone Number (where we can reach you)*

Best Time To Call*

E-Mail Address*

Best Way To Contact You*

Current Policy

Current Insurance Company*

Policy Number*

Expiration Date*

Farm Information

Official Name of Farm*

Primary Farm Location Address*

City*     State*     Zip*  

Acreage*

Amount of Coverage for Home*

Year Home Built*

Home Construction Type*
Frame Home
Brick Home
Other (specify in comments box below)

Number of stories (levels)*
One
Two
Three
Four or more

Square Footage of Home*

Do you have any other farm locations?  If so, please list below:

Please list and describe the barns you have on the property:*

Do you currently insure your implements and machinery?  Please list below:*

What limit of liability do you carry?*

What type of farming do you perform?*

How many full time employees do you have?*

How many part time employees do you have?*

Do you have any horse exposure?*

Questions/Comments:

Please note that this form is for a request only.  By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, assume we did not get this request for an insurance quote, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

I have read and agree with the above disclaimer (it is mandatory to check box before request can be sent).