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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY COLONY (Risk Placement Services, Inc.)

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COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
COLONY NATIONAL INSURANCE COMPANY
CONTRACT DIVISION - FARM and RANCH APPLICATION
Edition date 09.01.14
Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insureds Phone Number:
Insured’s Web Address:
BUSINESS TYPE
Individual Joint Vent LLC Religious Partnership Other: ________________
QUOTE
New Business Renewal Expiring Policy Number: ________________________
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business under the ‘Named Insured’ indicated on this application
_____ Years experience in the operations indicated within this application Attach resume(s) if available
Applicant has had their policy cancelled or non-renewed in the past three years
LOSS HISTORY
Three years of loss history information provided attached to this application
OPERATIONS / EXPOSURES
Describe your farm and ranch operations (business activities are covered later in the application):
Homeowners insurance will be placed with another carrier
Insured serves on outside boards
Name(s) of board(s): ________________________________________________________________________
Subsidiary companies exist but are insured elsewhere
Names of Subsidiaries: ______________________________________________________________________
Retail Agent has personally inspected the premises
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FARM and RANCH APPLICATION - LOCATION SCHEDULE
LOCATION INFORMATION (Mandatory for both farm liability and farm property)
Seasonal use. If “yes” advise which location(s): ________________________________________________
Vacant If “yes” advise which location(s): _____________________________________________________
Vacant over 2 yrs If “yes” advise which location(s): ____________________________________________
Seasonal/Vacant Property(s) checked: Monthly Bi-Weekly Weekly
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
Loc
Bldg
Address including Zip Code:
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FARM and RANCH APPLICATION - LIABILITY
DEDUCTIBLE – LIABILITY – (per occurrence)
$500 $1,000 $2,500 $5,000 $10,000
COVERAGE OPTIONS: (Check only the options you want applied to your quote)
Controlled/Prescribed Burns and Chemical Drift (Third Party Liability) provided with a $25,000 sublimit at no
additional premium charge. Select one of the following if you need higher limits:
$50,000 sublimit for $500 $100,000 sublimit for $1,000
Check if applicable:
Insured conducts controlled burns on their property. If “yes” what is the average number of
controlled/prescribed burns per year: ____________
All controlled burn permits and fire department notifications are secured where required
A Wildfire mitigation / Vegetation control is ongoing within 150 ft. of all insured structures
Identity Recovery (i.e. Identity Theft) - $19
Liquor Liability:
• Available with vineyard/winery risks only
• Not available in: AK, AL, CT, DC, DE, HI, IA, IL, IN, MA, MD, ME, MI, MN, MO, NH, NJ, NY, OH,PA, RI,
VA, VT, WV
Employees serving alcohol have liquor training such as TIPS or TOPS
Annual receipts for liquor served on or off vineyard premises: $ _________________
Products / Completed Operations to be EXCLUDED:
ASSAULT AND BATTERY:
• Not sub-limited
SUBCONTRACTED LABOR:
• Injury (BI, PD, and AI/PI) that occurs to any uninsured temporary workers, volunteer workers, casual workers,
independent contractors, or farm employee of an independent contractor is excluded.
• Injury caused by uninsured subcontracted labor to third parties is not excluded.
NOT AVAILABLE:
• Aggregate Per Location‟ or „Aggregate Per Project‟
• Higher Limit Farm Liability (seek Excess/Umbrella instead)
• Hired and Non-Owned Auto
• Host Liquor (buyback not available)
• Personal and Advertising Injury coverage for risks with „organic‟ farming exposures
• Professional Liability
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FARM and RANCH APPLICATION - LIABILITY
OWNED OR LEASED ACREAGE – RISKS UP TO 150 ACRES – FR01518
OWNED OR LEASED ACREAGE – RISKS ABOVE 150 ACRES – FR1618
• Required rating step for all Farm/Ranch risks
• All owned, leased and/or vacant land regardless of use or non-use
• 1 sq. mile = 640 acres
• Code FR01518 applies to policies with 150 acres or less
• Code FR01618 applies to policies with more than 150 acres
• Prohibited:
• Dams or levees with the exception of low height retention ponds used for watering
animals; Mines, Open pits, Quarries and/or Strip mining
Number of Acres:
AQUA-CULTURE - FR56760 (Check only those that apply)
Certified by the Aqua-Culture Certification Council (ACC)
Chemical and drug handling is always done to mfg’s specifications
Licensing: All applicable Federal, State and/or Local licensing permits
have been obtained and are on file
Recalls: Production/sales documentation in place to assist in the event
of a product recall
Testing of product is in place and meets all applicable USDA standards
Waste/sediment handling is per all applicable environmental standards
• Prohibited:
• Ocean marine exposures
Annual Receipts:
$
BEES, CROPS, NURSERY STOCK, NUTS, PLANTS, SOD, TREES – FR01901
• Acreage used for beekeeping, berries, crops, field or forage crops, flowers, fruits, grain,
herbs, honey, legumes, mushrooms, nursery stock, nuts, plants, spices, sod, straw, trees,
vegetables, vineyards
• Do not include acreage devoted solely to the raising of animals
• Prohibited:
• Rooftop farming and Tobacco Farming
Number of Acres:
ANIMALS AND LIVESTOCK – FR01391
• Number of head of cattle, donkeys, goats, horses, mules, sheep, swine or exotics (i.e.
alpaca, bison, deer, llamas, yaks)
• Do NOT include birds/poultry, or animals being raised for their fur
• Check only those that apply:
Fences inspected and repaired on a regular basis
Fence heights are appropriate for animal type(s)
• Prohibited animal exposures:
• German Shepherds, Huskies, Mastiffs, Pit Bulls, Rottweilers
! Exotic animals that are inherently aggressive or vicious (i.e. alligators, bears,
venomous snakes, wild cats, wolves or similar
• Racing type to include breeding, boarding, training or ownership
• Saddle animals if provided for use by third parties
• Stabling of animals prohibited, unless no fee/receipts are charged
• Training of any type of animal that includes a third party as part of the exposure.
Example would be riding lessons, pet training with owner.
• Zoos, Petting Zoos
Number of Head
POULTRY AND BIRDS – FR07230
Annual Receipts:
$
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FARM and RANCH APPLICATION - LIABILITY
BUSINESS ACTIVITIES AND BUSINESS PURSUITS – EXCLUDING CONSTRUCTION,
REMODELING OR RENOVATION – FR01235 (Check applicable items only)
Total Receipts for
Business
Activities:
$ _________
Exclude project
costs related to
Construction,
Remodel,
Renovation
-----
Exclude Income
derived from
leases related to
oil and gas wells
and/or wind
turbines
Aircraft or Aircraft Related Facilities are prohibited
Amusement/Recreation/Sports/Vacation - Submit if not on prohibit list below.
• Amusement rides including arcade rides, bounces, bounce houses, and inflatables
are prohibited
Archery ranges
Athletics or sports activities (describe): ___________________________
Beaches, Lakes, Ponds (Mandatory: If a fee is charged for property access then third
party swimming must be prohibited and area posted ‘No Swimming’
Boats and watercraft (Max length 26 ft – motors not exceeding 50 HP)
Cabin – Vacation Rentals
Campgrounds
Carriage rides are prohibited
Caving and spelunking by third parties is prohibited
Corn maze / pumpkin patch
Dude ranches - Guest participation in actual farm/ranch activities is prohibited
Fishing (including tournaments)
Fishing Piers (Oceanside exposures prohibited)
Guide and Outfitting
Hang gliding by third parties is prohibited
Haunted Houses are prohibited
Haunted Forests are prohibited
Hay rides – Public road exposure and speeds above 5 mph are prohibited
Hot air ballooning by third parties is prohibited
Hot Springs are prohibited
Hunting by third parties on Insured’s premises
Ice skating by third parties is prohibited if a fee is charged
Paintball activities involving third parties prohibited
Parachuting is prohibited
Picnic grounds/facilities used by third parties
Playground offered for use by third parties
Racing or Competitions with ‘motorized equipment’ or motorized vehicles including but not
limited to ATV’s, Autos, Dirt bikes, Motorcycles, Snowmobiles, tractors (including Tractor
Pulls), Trucks or misc. types of motorized farm machinery or equipment are prohibited
Rafting by third parties – Class III, IV or V rapids are prohibited
Rifle, Pistol or Skeet Ranges
Rock climbing by third parties
Rodeo on Insured’s premises
Sleigh rides are prohibited
Special Events involving third parties
Tours of premises offered to third parties
Trails for use by third parties (hiking trails acceptable)
• Trails for ATV’s, Dirt bikes, Horses, Motorcycles, Skiing or Snowmobile trail use
by third parties are all prohibited
Trampolines are prohibited
Water Skiing by unrelated third parties prohibited
Zip Lines exposures prohibited
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FARM and RANCH APPLICATION - LIABILITY
BUSINESS ACTIVITIES AND BUSINESS PURSUITS - EXCLUDING CONSTRUCTION,
REMODELING OR RENOVATION - FR01235 (continued)
Artificial Insemination for third parties
• Mandatory: Semen sales acceptable only if they can not be traced to a specific
animal, or related to a prize animal
Auctioneering for third parties
Bartering of goods or services
Breeding of cats, dogs, rabbits
Christmas Tree Farm
Custom Farming/Ranching (i.e. Subcontracting to third parties):
Farm machinery operations for third parties
Orchard or Vineyard Operations Performed for third parties
Other – Describe:
• Custom Farming including bale chasing, crop dusting, herbicide and pesticide work
and silage pile work are prohibited
• Generally if 100% custom farming risks are prohibited, exceptions are ‘Farm
Machinery Operations by Contractors’ and/or ‘Fruit or Vegetable Harvesting
Contractors’
Daycare - Foster Care - Misc. Education
Drying Facilities (gas or electric) for grain or similar are prohibited
Dumps and Landfills are prohibited
Farmers Markets -Concession Stands – Restaurants – Retail conducted off-premises
Feed, Grain, Hay Dealers, but only if sales off-premises
Feedlots - Containment Operations - Yard Confinement, but only if for third parties.
• Mandatory: No more than 300 head in confined areas with no natural grazing east of
the Mississippi River (excluding IL and WI). No more than 500 head in all other states.
Grain Elevators and Grain Storage Bins
• If active dust controls systems are in use then the exposure is prohibited
Grain Milling for third parties
Grain Storage for third parties
Hazardous materials application, handling and/or storage for third parties is prohibited
Leasing to Third Parties – Buildings (including habitational)
• Mandatory: Tenant’s operations and exposures must be of a type normally acceptable
in Contract binding
• Mandatory: Stoves (coal, pellet or wood) must be installed to code or to
manufacturer’s specifications (when no local building codes apply). Space heaters &
portable kerosene heaters used as primary heat sources prohibited.
Leasing to Third Parties – Land
• Mandatory: Tenant’s operations and exposures must be of a type normally acceptable
in Contract binding
• Describe tenant’s operations (if any):
Leasing to Third Parties (oil and gas wells and/or wind turbines only)
• Leasing related to energy related facilities such as ethanol facilities or mining are
prohibited
• Mandatory: Must be owned, maintained and operated by third parties
• Owner/operators must provide certificates confirming general liability coverage with at
least $1MM limits and confirm Additional Insured status for our insured.
• Do NOT include receipts for these exposures as we do not cover this exposure
% %
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FARM and RANCH APPLICATION - LIABILITY
BUSINESS ACTIVITIES AND BUSINESS PURSUITS EXCLUDING CONSTRUCTION,
REMODELING OR RENOVATION – FR01235 (continued)
Livestock Dealers/Commission Merchant for third parties
Livestock Sales done for third parties
Manure and Methane Digesters are prohibited
Meat Processing done for Insured or for third parties
Packing House Operations for Third parties
Pick-Your-Own Fruits, Nuts, Vegetables
Produce Handling or Packing for third parties
Rental or Leasing of machinery or equipment to third parties
• Mandatory: Fees/receipts must not be collected
Repairs, Build or Design of machinery, equipment and/or vehicles
• Mandatory: Fees/receipts must not be collected
Retail Stores – Not Food – On or Off the Insured’s Premises
• Mandatory: There must not be any sales of non-pasteurized dairy or juice products
directly to the final consumer
Smoking of Meat, Fish or Seafood for Insured or third parties
• Mandatory: Smoking must not be conducted within 50 ft. of any insured structure
Snow Removal for third parties
Special Events for third parties - Describe:
Stabling of Animals for third parties
• Mandatory: Fee/receipts must not be collected
Stockyards that have animals owned by third parties
Towers owned and/or maintained by insured
• Mandatory: Must not exceed height of 72 feet
Wine Manufacturing, Processing, or Retail Sales
Other (Describe):
BUSINESS ACTIVITIES AND BUSINESS PURSUITS -
CONSTRUCTION, REMODELING AND UPDATING EXPOSURES ONLY – FR01236
Insured has Construction/Remodeling/Repair/Updating exposures for owned structures
on the Insured’s premises
Third party contractors are used who provide certificates verifying liability limits
At or equal to the insured’s, as well as workers compensation
Insured is acting as their own general contractor
Insured is doing some or all of the construction related work
Total Combined
Cost of Project(s)
$
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%%
FARM and RANCH APPLICATION - LIABILITY
MISCELLANEOUS LIABILITY
ATV’s or Snowmobiles:
• Prohibited: Off-premises use, Recreational use, Three- wheeler type, Use by third parties
Number:
BOATS – NOT FOR RENT - FR45523
• Maximum 50 hp engine & maximum 26 foot length
Number:
BUNKHOUSE OR DORMITORY - FR09253
• Total number of buildings (up to 12 beds count as one building)
Number:
DWELLINGS – OWNER OCCUPIED - FR09250
• Owner Occupied only (rentals are rated under step 3)
• Mandatory: Stoves (coal, pellet or wood) must be installed to code or to manufacturer’s
specifications (when no local building codes apply). Space heaters & portable kerosene
heaters used as primary heat sources prohibited.
Number:
LAKES OR RESERVOIRS - FR40017
• Combine all into one total acreage figure
Total Acres:
SWIMMING POOLS - FR48925
• Mandatory: Fully fenced, self locking gates, depth marked, rules posted, safety equipment
provided.
• Only below ground pools are counted for rating purposes.
• Prohibited - Diving boards or slides above 3 feet or 1 meter in height
Number:
STORAGE TANKS – FLAMMABLES – ABOVE GROUND STORAGE (AST’s)
Check only those that apply:
Anhydrous Ammonia storage tank exceeding 500 gallons
Individual above ground storage tank(s) (AST’s) with more than 100 gallons of flammables
Individual LPG bulk liquid storage tank with more than 2,000 gallons of LPG
All Federal, State and Locally required precautions in place in regard to dikes to contain
spills, vehicle barriers and warning signage to include ‘No Smoking’
All required inspections have been completed and all recommendations complied with
All required permits in place and current
TOTAL ANNUAL RECEIPTS FROM ALL OPERATIONS
• Include receipts from all farm, ranch, business activities or business pursuits intended to
be covered under this policy
$
% %
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%%
FARM and RANCH APPLICATION - LIABILITY
ADDITIONAL INSUREDS (A.I.) - LOSS PAYEES – WAIVERS OF SUBROGATION
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Circle only those that apply: A.I. Waiver of Subrogation Loss Payee
Entity / Address:
Relationship to Insured: Customer Other: _______________________________________
Page%10%of%18%
%
FARM and RANCH APPLICATION - PROPERTY
PROPERTY ‘PER OCCURRENCE’ DEDUCTIBLE (APPLIES TO COVERAGES A, B, C, D, E, F, G)
$500 $1,000 $2,500 $5,000 $10,000
PROPERTY – FARM AND RANCH - WIND AND HAIL
• Risks with property exposures in the following coastal states and some non-coastal states with tornado
exposures may be subject to special wind and hail coverage restrictions:
• AL, AR, CO, CT, DE, FL, GA, HI, IL, IA, KS, LA, ME, MD, MA, MN, MS, MT, NE, NH, NJ, NM, NY, NC,
ND, RI, SC, SD, TX, VA, WI, WY
%
PROPERTY COVERAGE A – DWELLINGS
PROPERTY COVERAGE B – OTHER PRIVATE STRUCTURES APPURTENANT TO DWELLINGS
PROPERTY COVERAGE C – HOUSEHOLD PERSONAL PROPERTY
PROPERTY COVERAGE D – LOSS OF USE
Occupied, Seasonal Occupancy or Vacant:
• Habitational Property to include Dwellings (owner occupied or third party occupied), Employee
Housing (including employee dorms and employee bunkhouses) and Vacation Rentals are all eligible
to be covered with any combination of Coverage A, B, C and/or D
Cause of Loss (Choose One): Basic Broad Special
Coinsurance: 80%
Valuation – Coverages A & B (choose One): ACV RC
Valuation – Coverage C (choose One): ACV RC
Coverage Trigger for A, B, C and/or D:
• A limit for A, B, C and/or D must be indicated for each Coverage individually
• Declaring a Coverage A limit does not trigger coverage limits for Coverages B, C and/or D
Premium Charges:
• A Coverage A limit will result in a waiver of premium charges for the following:
• Cov B Limit – Up to 10% of Coverage A limit
• Cov C Limit – Up to 50% of Coverage A limit
• Cov D Limit – Up to 20% of Coverage A limit
%
%
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
Page%11%of%18%
%
FARM and RANCH APPLICATION - PROPERTY – COVERAGES A THRU D
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
LOC
#
BLDG
#
Bldg Area
Construction
Year
Built
Protection
Class
Building Systems Updating
(Circle if updated within past 25 years)
Electrical Heating Plumbing Roof
Mobile home
A – Dwelling
$
B – Personal Use Structures
$
C – Household Personal Property
$
D – Personal Property Loss of Use
$
Page%12%of%18%
%
FARM and RANCH APPLICATION - PROPERTY – COVERAGE E
PROPERTY - COVERAGE E – SCHEDULED FARM PERSONAL PROPERTY
Cause of Loss (Choose One): Basic Broad
Coinsurance: 80%
Valuation: ACV at time of loss, RC subject to policy conditions
#
ITEM
LIMIT OF INSURANCE
1
Grain, Beans, Ground feed, “Livestock” feed, Silage, Threshed seeds -
• In buildings, structures, sacks, trucks or wagons only
$
2
Grain in stacks, shocks, swathes or piles –
• In the open only
$
3
Hay, Fodder, and/or Straw – In buildings or structures only
• Maximum available limit is $25,000
$
4
Hay, Fodder in stacks, windrows or bales and/or Straw – In the open only
• Maximum available limit is $10,000
$
5
Computers & Related Software
• Use must include Farm, Ranch and/or Business Activities/Pursuits
• Personal use only to be declared under Coverage C instead
$
6
Farm Products, Materials, Supplies
• But not hay, grain, feed, fodder, silage, seeds, straw (see # 1 & # 2 above)
7
Misc. Equipment – Values are $1,000 Per Item or Less
Check this box if limit includes beekeeper equipment
• Machinery, supplies, tools or vehicles usual or incidental to farm operations.
• Declare as one blanket limit
• Off-premises coverage only available if you schedule items individually under
# 12 below
$
8
Rented/Borrowed - Equipment, Machinery and/or Farm Vehicles
• Declare all values, even if no written contract
• Declare as one blanket limit
$
9
Trays, Boxes, Box shook (i.e. unassembled wood crates)
$
10
Farm Machinery, Equipment or Vehicles – Values exceed $1000 per Item
Check this box if golf mobiles are scheduled below
Check this box if beekeeper equipment is scheduled below
• Items MUST be scheduled here if you need off- premises coverage
• Blanket coverage not available for scheduled items
• Loss on an individual item will be limited to the declared value for that item
Limit of Insurance on
a ‘per item’ basis
Year
Description – Make – Model
Value of Item
$
$
$
$
$
$
$
$
$
Schedule E continues on next page
Page%13%of%18%
%
FARM and RANCH APPLICATION - PROPERTY – COVERAGE E
PROPERTY - COVERAGE E – SCHEDULED FARM PERSONAL PROPERTY (continued)
10
Farm Machinery, Equipment or Vehicles (continued)
Valued over $1000 per Item (continued)
• Items MUST be scheduled here if you need off- premises coverage.
• Blanket coverage not available for scheduled items
• Loss on an individual item will be limited to the declared value for that item
Limit of Insurance on a
‘per item’ basis
Year
Description – Make - Model
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
SUBTOTAL OF LIMIT OF INSURANCE FOR FARM MACHINERY, EQUIPMENT
OR VEHICLES VALUED OVER $1000 – COVERAGE E – ITEM # 10
$
Page%14%of%18%
%
FARM and RANCH APPLICATION - PROPERTY – COVERAGE E and F
PROPERTY - COVERAGE E – SCHEDULED FARM PERSONAL PROPERTY (continued)
Property coverage for Bees, Fish, “Livestock” or Worms does not include disease or mysterious disappearance
#
ITEM
LIMIT OF INSURANCE
11
“Livestock” - Actual Death/Destruction
• Covers property loss (see types of loss covered under Basis or Broad
Cause of Loss). Collision is only one type of loss covered if animal is killed
• Eligible:
• Cattle, donkeys, goats, horses, mules, sheep, swine, and exotics
(alpaca, bison, deer, llamas, yaks
• Describe unlisted exotic animal type here:
• Limit of Insurance = ‘number of head’ one year old or older times $2,000
plus ‘number of head’ under one year old times $1,000 plus the value of
any animal above these values (appraisal required to document value)
• Maximum limit per head - $1,000 if animal is under one year of age,
$2,000 per head if one year old or older. Any animal to be valued higher
must be declared, and the value must be supported by an appraisal.
• Prohibited - Property coverage for birds (including poultry)
$
12
Bees (Blanket Value) – Actual Death or Destruction
$
13
Fish (Blanket Value) – Actual Death or Destruction
• Only fish raised for food consumption are eligible for property coverage
$
14
Worms (Blanket Value) – Actual Death or Destruction
$
15
“Livestock” - Collision Only
• Covers property loss only due to collision if animal is killed
• Eligible:
• Cattle, donkeys, goats, horses, mules, sheep, swine, and exotics
(i.e. alpaca, bison, deer, llamas, yaks)
• Describe unlisted exotic animal types here:
___________________________________________________
• Limit of Insurance = ‘number of head’ times $1,000
• Maximum limit per head - $1,000
• Prohibited - Property coverage for birds (including poultry)
$
16
Misc. (describe):
$
17
Misc. (describe):
$
18
Misc. (describe):
$
19
Misc. (describe):
$
20
Misc. (describe):
$
TOTAL OF ALL COVERAGE E LIMITS OF INSURANCE
$
%
PROPERTY - COVERAGE F – UNSCHEDULED FARM PERSONAL PROPERTY
LIMIT: $5,000
Cause of Loss (Choose One): Basic Broad
Coinsurance: 80%
Valuation: ACV at time of loss, RC subject to policy conditions
Page%15%of%18%
%
FARM and RANCH APPLICATION - PROPERTY – COVERAGE G
PROPERTY - COVERAGE G - BARNS, OUTBUILDINGS AND OTHER FARM STRUCTURES
Do not place habitational use structures here, See Coverage A, B, C and/or D
Cause of Loss (Choose One): Basic Broad
Coinsurance: 80%
Valuation: ACV at time of loss, RC subject to policy conditions
LOC # - BLDG #
COVERAGE G
LIMIT OF INSURANCE
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
Loc:
Bldg:
BLDG. AREA: _______________ sq. ft.
DESCRIPTION–CONSTRUCTION-OCCUPANCY:
$
TOTAL OF ALL COVERAGE G LIMITS OF INSURANCE
$
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FARM and RANCH APPLICATION - PROPERTY – OPTIONAL COVERAGES
PROPERTY COVERAGE(S) - OPTIONAL (Check to Trigger Coverage Option)
LIMIT OF INSURANCE
Disruption of Farming Operations
• Blanket basis
• Coinsurance is 80%
• Does not provide coverage for business income related to ‘Business
Activities’ or ‘Business Pursuits’
• Includes ‘rental income’
$
Farm and Ranch Equipment Breakdown
Per Form U695
Increased Special Limits for ‘Business Personal Property’:
• Declare a higher sublimit here for ‘Business Personal Property’ under
‘Coverage C – Household Personal Property’
• Off Premises - 20% of on-premises limit will apply to off-premises exposures
for ‘Business Personal Property’
• Sublimit does not increase the applicable limit of insurance for Coverage C
$
Milk Contamination:
• Coverage for contamination of your milk, not milk of others
$10,000
Theft Exclusion:
• Total Theft Exclusion applicable to all property
NA
Theft Exclusion:
• Applicable to All Property except ‘Coverage C – Household Personal
Property’
NA
Misc. (Describe)
Misc. (Describe)
Misc. (Describe)
Misc. (Describe)
Page%17%of%18%
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FARM and RANCH APPLICATION - PREMISES DIAGRAM
FARM/RANCH PREMISES DIAGRAM
• Identify all buildings, lakes, ponds and storage tanks
• Identify any structure(s) not to be insured for property (if applicable)
• Indicate estimated distance between structures
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FARM and RANCH APPLICATION - PRIVACY, FRAUD and SIGNATURE PAGE
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE
COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE.
SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR
OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR
AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN
REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND
OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT
OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS
THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, KS,
MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION
TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES
INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF
FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN
APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY
OF THE THIRD DEGREE.
IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN
INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART
OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY
FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT
TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO
CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS,
FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A
FRAUDULENT INSURANCE ACT.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH
INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS
FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE
COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO
CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES
INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. IN WASHINGTON, IT IS A CRIME TO
KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY
FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND
DENIAL OF INSURANCE BENEFITS.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT
REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION.
HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
Signature / Date: ________________________________________________________________________________
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY COLONY (Risk Placement Services, Inc.)

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Completed 30 July 2020

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