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FARM LIABILITY COMMERCIAL GENERAL LIABILITY
Coverages Occurrence Aggregate
Fire Damage
Limit
Medical
Payment
Coverages Occurrence Aggregate
Fire Damage
Limit
Medical
Payment
Limit of Liability
$ $ $ $5,000
Limit of Liability
$ $ $ $5,000
Exclude Personal and Advertising Injury Include Products/Completed Operations
Exclude Advertising Injury Exclude Personal and Advertising Injury
LIABILITY
Loc # Code Coverage Exposure Basis
UNDERWRITING INFORMATION *
If the answer to any question is yes, please explain using the comments section
1. Does the agent know the applicant? Number of years: _______________
YES NO
2. Has the agent personally inspected the premises and property? Date of last inspection: _______________
YES NO
3. Has insurance been transferred within the agency?
YES NO
4. Are independent contractors hired to perform any farming operation?
YES NO
5. Are there any custom farming operations? Receipts $ _______________
YES NO
6. Are there any custom feeding operations? Type: _______________ Number of Head: _______________
YES NO
7. Is any part of the farm used or leased for organized recreational use?
YES NO
8. Does applicant build, repair or design machinery, equipment or systems for anyone for a charge or fee? Receipts $ _______________
YES NO
9. Does applicant mix, process, slaughter, butcher or otherwise prepare for any “end” consumer his or any other grower’s product?
YES NO
10. Does applicant handle any product, such as seed, fertilizer, sprays, etc. for resale?
YES NO
11. Are any contract or service operations performed for others such as tilling, excavating or ditching?
YES NO
12. Are the farm premises open to the public for roadside stands, “U-Pick,” recreational, “rent-a-garden,” auction, sales, show, food or beverage service, animal boarding,
hay rides, corn mazes or Christmas tree sales uses?
YES NO
13. Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other than farming?
YES NO
14. Does applicant prepare and sell animal feed?
YES NO
15. Are there any unusual hazards such as but not limited to: open dump pits, silage pits, sump holes, lakes, reservoirs and/or airstips on premises?
YES NO
16. Does the applicant have any potentially dangerous animals or exotic pets?
YES NO
17. Is any land held for real estate development or speculation?
YES NO
18. Is the applicant engaged in any other business, profession or trade?
YES NO
19. If livestock is kept, are all areas well-fenced? If no, please explain.
Premises is in: open range area closed range area
YES NO
20. Are the described insured premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other
than business property? If no, explain.
YES NO
21. Any private saddle animals owned? If so, use and number of animals?
If more than 4 animals, please complete equine liability questionnaire.
YES NO
22. Any non-owned horses on any insured premises?
If yes, must complete equine liability questionnaire and provide copy of hold harmless and boarding agreement.
YES NO
23. Are any of the insured farm dwellings or buildings unoccupied for more than 30 consecutive days during the policy period?
YES NO
24. Does applicant maintain any vacation, seasonal, or additional primary residence?
YES NO
