AGRIBUSINESS QUOTE REQUEST Agency InformationAgency Name:*Contact Name:*Contact's Email* Agency Phone*Agency Fax NumberApplicant InformationApplicant Full Name:*Applicant Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Phone Number*Requested Effective Date* Date Format: MM slash DD slash YYYY Prior Coverage* Date Format: MM slash DD slash YYYY Loss History*Type of Farm*Please Select OneLivestockPastureHobby farmTotal Acres*Total # of Locations**Total # of Locations w/Buildings:*Location InformationLocation Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Inside City Limits*YesNoLiability CoverageLiability Limit:Please Select One$500,000 / $1 Million$1 Million / $2 Million$2 Million / $4 MillionMedical Payment Limit:Please Select One$5,000$10,000List any business activities other than farming or ranching conducted at any insured location:*Any ATVs?*YesNoYear*Make*Model*Value*Add Another ATV?*YesNoYear*Make*Model*Value*Are there horses?*YesNoNumber of Horses*DwellingDeductible*Year Built*Mobile Home?*YesNoFoundation?*YesNoTotal Living Square Footage*Construction Type:*Roof Type:*Building Limit:*Update Year Roof:*Update Year Plumbing:*Update Year Electric:*Update Year Heating:*Garage Square Feet:*Garage Type*AttachedDetachedWood Stove?*YesNoWithin 1000 ft of hydrant?*YesNoWithin 5 miles of fire department?*YesNoProtection Class*Scheduled Farm Personal PropertyDo you have farm personal property?YesNoYear*Make*Model*Serial Number*Value*Do you want to add additional farm personal property?YesNoYear*Make*Model*Serial Number*Value*Do you want to add additional farm personal property?YesNoPlease attach scheduleBarns and OutbuildingsDo you have barns or outbuildings?YesNoYear Built*Square Footage*Construction Type*Roof Type*Value*Do you want to add another barn or outbuilding?YesNoYear Built*Square Footage*Construction Type*Roof Type*Value*Do you want to add another barn or outbuilding?YesNoPlease attach scheduleAdditional File Attachment 1Additional File Attachment 2Additional RemarksYou may be contacted by a commercial underwriter for additional information.
