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Farm Application Checklist Today'sDate ___/____/_______

Completedby:

ApplicantName: AgencyName:

BestTelephone#:

EmailAddress:

Applications with this information completed will receive preference in quoting. EffectiveDate___/____/______

DateQuoteNeeded: ___/____/_______

ExpiringPremium: $

ExpiringCarrierName: TargetPremium: $

Completed

byAgent

(Check off each Applicable)

√ CoverageSections,Applications,&InformationCompletedandAttached

o Dwellings‐Owned,Seasonal,andNon‐Owned‐CovA,B,C,D

● OlderDwellQuestionnaireOver40yrs

o ScheduledFarmPersonalProperty‐CovE

o UnscheduledFarmPersonalProperty‐CovF

o Outbuildings‐FarmBarns,Buildings,andStructures‐CovG

InlandMarine:

o PersonalProperty‐Jewelry,Furs,Cameras,MusicalInstruments,

Silverware,FineArts,GolfEquipment,Stamps,Coins,Firearms,Other

o RecreationalVehicles‐Boats,ATVs,Snowmobiles,GolfCarts,Other

DisruptionofFarmingOperations(IncomeLossandExpenseCoverage)

o DeterminetheRequiredLimit&CoinsuranceMinimums

FarmAutomobile

Didyouinclude?

o AllDriversincludingthoseEmployeeDriversUsingtheirOwnVehicles?

o ListofAuto/Truck(Lessthan3yearsold)requestingR.C.

o FarmExcess

o DiagramsofAllLocations

o PhotosofAllBuildingsandStructures

o SocialSecurityNumberoftheNamedInsuredorPrimaryPartnerorShareholder

o ReplacementCostWorksheets

o Claims‐LossRun

PerOccurrencePropertyDeduction

AdditionalInterests

Didyouinclude?

o AllMortgageInterests

o AllPersonalPropertyAdditionalInterests

o AllLiabilityAdditionalInterests

o IfApplicable:Equine,Dairy,Poultry,Swinequestionnaires

Reset Form

Performance Insurance Services, Inc. DBA James Allen Insurance Brokers is known in the state of New York as Performance Insurance Brokers.

Bind

Partnership

Field Crop

Field Crop Type

No Losses in prior 3 years plus current year

No Losses in 5 years

JAIB Appl 002 0412

DWELLING(ISOCOVERAGEA,B,C,&D)

Heat Wiring Plumbing Roofing

Cov

C**

DWELLING(ISOCOVERAGEA,B,C,&D)‐Continued

CovA CovC

*ValuationCoverageA:RC=ReplacementCost;ERC=ExtendedReplacementCost;ACV=ActualCashValue;FBV=FunctionalBuildingValuation.

**ValuationCoverageC:RC=ReplacementCost;ACV=ActualCostValue

^^Perils:B=BasicBR=BroadS=SpecialS/BR=Special/Broad

***Ifyearbuiltisover40years,completeolderdwellingsupplementalquestionnaire.

Ends:

Page2of8

UnoccupancyorVacancy

MORTGAGEEINFORMATION

Certaincausesoflossareexcludedwithrespecttobuildingsorstructuresvacantmorethan30consecutivedays.

Use'WaiverofVacancy'toextendcoveragebeyond30days.

Dwlg#

□ContractforSale

□Lender'sLossPayee

UNOCCUPANCYANDVACANCY‐ForDwellingsandALLOTHERBUILDINGS

Dwlg#orBldg#

NameandAddress/Loan#

□LossPayee

□ContractforSale

□Lender'sLossPayee

□ Mortgagee

AlossconditionreducestheapplicableLimitofInsuranceby50%ifabuildingorstructureisunoccupiedorvacant

morethan120consecutivedays.Use'WaiverofUnoccupancyandVacancy'towaivetheUnoccupancyand

VacancyLossConditionforperiodsofvacancyandunoccupancybeyond120days.

□LossPayee

NameandAddress/Loan#

Dwlg# □ Mortgagee

Starts:

JAIBAppl00010811

Loc

Dwlg

CovD:

LossofUse

Limit20%

CovC:

HouseholdPersonal

PropertyLimit70%

#of

Families

Ded

($1,000Min)

CovA:

Dwelling

Limit100%

ProtectiveDevices

CovB:

OtherStructures

Limit10%

Dwlg

Year

Built

***

Square

Feet

Valuation

Loc

RoofType

Typeof

Heat

Dwlg

Dwelling

Occupancy

(OwnerPrimary/OwnerSeasonal/Tenant)

Typeof

Construction

(Ifmobilehome,attach

questionnaire)

*AttachCostEstimatorforeach

dwelling

Sump

Overflow

(Y/N)

If40Yearsoldormore,

Whenwasitupdatedfor:

DWELLING(ISOCOVERAGEA,B,C,&D)‐Continued

Loc

Perils^^

Supplemental

Heat(Attach

questionnaire)(Y/N)

Earthquake

(Y/N)

□ Does Not Apply

□ Waiver of Vacancy

□ Waiver of

Unoccupancy and

Vacancy

Mine

Subsidence

(Y/N)

JAIB Appl 002 0412

Number Loc#

Ded.

$1,000Min

Limitsof

Insurance

PERILS

1 $$

2 $$

3 $$

4 $$

5 $$

6 $ NOTCOVERED

7 $$

8 $$

9 $$

10 $$

Loc#

Year

12 Ded.$500

Minimum

13 NOTCOVERED

#OfHead $ $

Loc

Item

Year Serial# CC/HP Length

Typeof

Motor

Ded.

$1,000

Min.

Limitof

Insurance

Year

JAIBAppl0010811 Page3of8

Poultry

OtherAnimals

Repl.Cost

LessThan5

YearsOnly

Foreign

Objects

(Y/N)

CabGlass

(Y/N)

Perils

Farmmachinery,vehicles,equipmentonorawayfromthe"insuredlocation"

Grain,threshedseeds,beans,groundfeed,silage,"livestock"feed,allinbuildings,structures,sacks,wagonsortrucks.

PropertyType

Farmmachinery,(non‐auto)vehiclesandequipmentthatyouborroworrentwithoutawrittencontract.

MiscellaneousEquipment(nottoinclude–Tractors,Combines,Autos,LPorContainers,Tanks,Brooders,Fences,

Towers–Poles,IrrigationEquipment,PortableBldgs,orHouseholdPersonalProperty)–Limitperitem$2,000

Serial#

□ Mortgagee

□LossPayee

□Lender'sLossPayee

PhysDamage

(Y/N)

Livestock(Cattle,Sheep,Swine,Goats,Horses,Mules,Donkeys)onorawayfrompremise.Valuation–theleastof(1)

AmountofInsurancedividedbynumberofanimalstimes120%,(2)ACV,or(3)$2,000.[And ½valueforAnimals

under1yrinAge]Perils:BasicorBroadonly.

LimitPerHead

Liability

(offpremises)

(Y/N)

NameandAddress

Limit

Item#



□Lender'sLossPayee

□LossPayee

□ContractforSale □ContractforSale

NameandAddress

ADDITIONALINTERESTS

□ Mortgagee

Description

ScheduledPersonalItems(Jewelry,Guns,Stamps,Art,ect)

AnimalCollision

RECREATIONALVEHICLES

Computers&relatedsoftwareusedprincipallyasaidsinFarmManagement

Trays,boxes,boxshook(unassembledwoodcrates).

Farmproducts,materialsandsuppliesshownincludingpackingmaterials&containers,butnothay,grainoranygrowing

crops.

Hay,straworfodderintheopen‐$10,000LimitperStackwitha100’separation/clearancebetweenStacks.Causesof

Loss‐fireorlightning,windstormorhail,vandalism,vehicles,andtheft.

Hay,straw,fodderinbuildingsorstructures.

Graininstacks,shocks,swathsorpilesintheopen,butonlywiththeseCausesofLoss‐fireandlightning,vandalism,

vehiclesandtheft.

COVERAGEE‐SCHEDULEDFARMPERSONALPROPERT

Perils:B=BasicBR=BroadS=Special

ItemCoverageNotes‐SeepolicyforDetails

EndDate

GRAIN&FEEDPEAKSEASON‐FARMPERSONALPROPERTY(ISOCOVERAGEE)

Item#

Description‐Make,Model,andSerial#

BeginningDate

JAIB Appl 002 0412

Agricultural

Machinery&

Implements

#of

Units

Unit

Price TotalValue

Agricultural

Produce

#of

Units

Unit

Price

TotalValue

AgriculturalTools,

Equipment

Supplies

#of

Units

Unit

Price

TotalValue

Tillage: Barley Agri‐Chemicals

Tractors

Corn Fertilizers

Fruit Herbicides

GroundFeed Insecticides

MfgStockFeed Pesticides

Nuts AirCompressors

Oats Bins

Discs Silage BoxesandBoxShook

Harrows Soybeans ElectricMotors

Plows Straw FarmLubricants

Other Wheat Fencing&Posts

Gasoline/DieselFuel

Cultivating: HandTools

Cultipackers Materials&Supplies

Cultivators MilkingEquipment

Drills OfficeEquipment

Planters Paints

RotaryHoes PickingEquipment

Speeders Livestock

#of

units

Unit

Price

TotalValue PoultryEquipment

Spreaders DairyCows PowerTools

Sprayers DairyHeifers Saddles&Tack

DairyCalves SpareParts

Harvesting: BeefCows Tires

Augers BeefCalves VetSupplies

Blowers FeederCattle Welders&Torches

Choppers Bulls Misc.Tools

CornPickers Sows&Gilts Misc.Parts

Driers Boards

Elevators(Port.) FeederPigs

ForageHarvesters Ewes

GrainCleaners Rams

GrapeHarvesters Lambs

HayBalers Horses

Mowers Ponies

NutShakers Mules

Rakes

RiceHarvesters

SiloFilters

SiloUnloaders

TomatoHarvesters

Wagons

Deductible

Total

*Perils:B=BasicBR=BroadS=Special

JAIBAppl0020312 Page4of8

Limitofinsurance

TotalValue $

Livestock(Basicand

BroadOnly)

OtherThanLivestock

Perils*

Item

CoverageFInventory

1.WithMultiguardEndorsementtheIrrigationEquipment,

Combines,andCottonPickersareeligibleforcoverageunderthe

CoverageF.–UnscheduledFarmPersonalPropertyform.

2.TheCauseofLossofForeignObjectsinFarmmachineor

MechanicalHarvesterisonlycoveredwhenpolicycontains

MultiguardEndorsementwithSpecialCauseofLoss.

3.80%CoinsuranceClauseRequired.

4.RequestCabGlassCoveragebyAddingaListofUnitswith

Description/ID#

5.RequestReplacementCostLossSettlementCoveragefor

Machinery&Equipment(5yrsornewer)byIncludingaListwith

UnitDescription/ID#andReplCostValues.

UNSCHEDULEDFARMPERSONALPROPERTY(ISOCOVERAGEF)‐ACVVALUATION

AGRIBUSINESSUNSCHEDULEDFARMPERSONALPROPERTYADDENDUM

TotalValue $

TotalValues $

APPLICANTNAME

TotalValue

DATE(MM/DD/YYYY)

JAIB Appl 002 0412

Loc# Bldg#

Year

Built

Square

Feet

Typeof

Const

RoofType

Roof

Age

Typeof

Heat

ProtectiveDevices

Loc# Bldg#

Mine

Subsidence

(Y/N)

EQ^^

(Y/N)

IG%

Open

Foundation

(Y/N)

Open

Sides

(Y/N)

Valuation*

Ded

Min

$1,000

Perils** LimitofInsurance

**Perils:B=BasicBR=BroadS=Special ^^EQ=Earthquake

JAIBAppl0020412 Page5of8

LimitRequested:$_______________________Min.Co‐InsuranceLimitRequired:$________________________

Notes:

FarmIncomeExcluded:_______________________

Co‐insurance%Requested(i.e30%,40%,50%,60%70%,80%)_________%

ExtendedPeriodofIndemnity(30,60,90,120,180,360)_________days

NameandAddress

□ Lender'sLossPayee

□ContractforSale

□Lender'sLossPayee

□ LossPayee

□ContractforSale

□ LossPayee

Bldg# □ Mortgagee

NameandAddress

Bldg# □ Mortgagee

FARMBARNS,BUILDINGSANDSTRUCTURES(ISOCOVERAGEG)

Description

FarmReceipts:$_________________________

MORTGAGEEINFORMATION

EquipmentBreakdownCoverage

□ Yes □ No

FARMBARNS,BUILDINGSANDSTRUCTURES(ISOCOVERAGEG)‐continued

DisruptionofFarmingOperationsandEquipmentBreakdown

* ValuationCoverage:RC=ReplacementCost;ACV=ActualCashValue;FBV=FunctionalBuildingValuation.

JAIB Appl 002 0412

FireDamage

Limit

Medical

Payments

Fire

Damage

Limit

Medical

Payments

$$ $$

√

JAIBAppl0010811 Page6of8

FARMLIABILITY□ COMMERCIALGENERALLIABILITY□

Coverages Occurrence Aggregate Coverages Occurrence Aggregate

FarmEmployee'sMedicalPayments

□ ExcludePersonalandAdvertisingInjury

#FullTime

Employees

#PartTime

Employees

EmployersLiability

LOC#

Mandatory

LimitofLiability

(UpTo$500,000Limit)

TotalPayroll

Limits

FarmEmployer'sLiability

$LimitofLiability

□ ExcludePersonalandAdvertisingInjury □ IncludeProducts/CompletedOperations

$$ $

LIABILITYCOVERAGE

$5,000

□ ExcludeAdvertisingInjury

□

DayCareCoverage(Home) NotEligible

RoadsideStands‐‐FarmProductsPrincipallyOnTheInsuredFarm

(RatePer$1,000GrossSales)

AdditionalResidenceRentedToOthers

TotalAcres

Acres

LOC#

12.Howfarawayfromstructuresisgasolineorfuelstored?Distance:____________(ft)

13.Whatarethegrossannualfarmingreceipts?$________________

11.Whatistheradiusofoperationofequipment?Miles:__________

1. Doestheagentknowtheapplicant?Numberofyears:_________Dateoflastinspection:__________________

ContingentLiabilityForCropDustingByIndependentAircraft(Rate

Per$1,000Cost)

Cost

Limit

UNDERWRITINGINFORMATION

*Iftheanswertoanyquestionisyes,pleaseexplainusingtheRemarkssection

AdditionalFarmPremisesMaintainedByNamedInsured

AdditionalNon‐FarmPremisesOccupiedByInsured

□ Seasonal □Permanent

DomesticWorkers'Comp

Inservant

#OfResidentialEmployees

Sales

Receipts

#Families

OtherCoverages Limits

CustomFarmingReceipts(RatePer$1,000)

Outservant

LimitedFarmPollutionLiability(ReferToCompany)

□ YES □ NO

3.Istheapplicantengagedinanyotherbusiness,professionortrade?

2.Hastheinsurancebeentransferredwithintheagency?

□ YES □ NO

6.Isfarmingtheprimarysourceofinsured'sincome?

10.Doyouowndogs?Ifyes,howmanyandwhatbreed?#_____Breed:___________________

8.Isthereaswimmingpoolortrampolineonthepremises?

Ifyes,pleasecompletetheswimmingpool/trampolinequestionnaireandattachphoto.

4.Anyprivatesaddleanimalsowned?Ifso,useandnumberofanimals?

5.Isanypropertykeptonlocation(s)otherthaninsuredlocation?

9.Pleaselistallthenamesofallofficers/ownersofthefarmingentity(Corporation,Partnership,JointVenture,LLC):

7.Doesapplicantmaintainanon‐farmoffice,privateschool,and/ordaycareinaninsuredbuilding?

□ YES □ NO

Total Acres

JAIB Appl 002 0412

ExplainAll'YES'Responses Yes No ExplainAll'YES'Responses Yes No

Areindependentcontractorshiredtoperformany

farmingoperations?

□□

Istheapplicantasubsidiaryofanotherordoesthe

applicanthavesubsidiaries?

□□

2Isthereanairstriponthepremises?

□□

15 Isaformalsafetyprograminexistence?

□□

Isanypartofthefarmusedorleasedfororganized

recreationaluse?

□□

16 Whattypeoffencingisused?__________________

17 Howfaristhefencingfromtheroad?_______________________

18 Howoftenisfencingchecked?_____________________________

Doestheapplicantallowotherstodisposeofwaste

materialsonthepremises?

□□

Haveanyoftheapplicant'slivestockeverescapedonto

publicroad?Ifyes,describeintheremarkssectionfrequencyofescape

andmeasurestakentopreventrecurrence.

□□

6 Areany'holdharmless'or'indemnifying'agreementsineffect?

□□

Hastheinsuredhadanycomplaintsregardingagri‐chemicaldriftorany

pollutiontoothersinthepastfiveyears?

□□

21 Isthereanyequipmentloanedorrentedto/fromothers?

□□

Doesinsuredplananyconstructionorrenovationworktobedoneon

thepremisesinthenext12months?

□□

8Isentirepremisesoccupiedyearround?

□□

23 Doestheapplicantdirectlysupervisethefarm?

□□

9Isentirepremisesoccupiedbyapplicant?

□□

Duringthelasttenyears,hasanyapplicantbeenconvictedofany

degreeofthecrimearson?(InRI,failuretodisclosetheexistenceofan

arsonconvictionisamisdemeanorpunishablebyasentenceofupto

oneyearofimprisonment.)

□□

Areanyburglaryand/orfirealarmsonthepremises?

Indicatefloorsprotectedbythealarm:________

IfYes,TypeofAlarm:___________

DiagramNumber:_____

□□

Isequipmentwellmaintained?Ifnot‐indicatewhatrepairsneedtobe

made,whentheserepairswillbecompleted,andthenameof

contractorperformingtherepairs

□□

Doesapplicantmaintainanyvacationorseasonal

premises?

□□

27 Showpolicynumber(s)ofotherinsurancewithFFIC

13 Doesapplicantserveonanyboardsforremuneration?

□□

JAIBAppl0020412

□

Arethereanyunusualhazardssuchas(butnotlimitedto)

opendumppits,silagepits,sumpholes,ponds,lakes,reservoirs,waste

lagoons,irrigationditches,trampolinesorothertypesofgymnastic

equipment?

Page7of8

Isthereayear‐roundwatersupplyusableforfireprotection?

IfYes,(A)Source= (B)Quantity=

□Well □LessThan1,000Gallons

□Pond/Lake □1,000‐3,000Gallons

□HydrantWithin1,000FT. □Over3,000Gallons

□ Other:

Remarks:

Areanywoodorcoalfiredstovesusedinanybuildings?

IfYes,CompleteWoodBurningStoveQuestionnaire

□□

GENERALINFORMATION

□□

Arethereanypublicparks,golfcourses,schools,churches,

stores,subdivisions,town/citiesoranypublicexposuresneighboring

anyoftheinsured'sfarmlocations?

□□

□

JAIB Appl 002 0412

Yes

Indicate if the Insured Does Any of These Activities Explain all YES Responses

1. Manufacture, Process, Handle, Apply, or Distribute of Any Products to others (and/or for hire or a charge)

of any of the following:

Dairy- Processing of Milk or Milk Products

Dairy- Sale of Raw Milk or Milk Products to the Public

Livestock (or Other) Feed

Feed, Seed, Grain, Fertilizer, Chemicals, Additives

Other Farm or Non-Farm Products on or off Premises

2. Livestock Slaughter, Butcher, or Otherwise Prepare and Products for Others and or Sale to Others

3. Build, Repair, Or Design Buildings, Equipment, or Systems for anyone for a charge. Or any Snow

Removal, Tiling, Excavating, or Ditching Services or Operations for a charge

4. Custom Farming- Planting, Cultivating, Field Application, Crop Care, Harvesting, Or Crop Dying

5. Any of the Following?

Animal Boarding

Auctions or Sales

Dangerous or Exotic Animals

Events for a charge- Parties, Weddings, or Meetings

Fishing or Hunting for a Charge

Equine Activities (Owned or Non Owned Horses)

Hay Rides

Kennels

Lodging (Bed & Breakfast) for a Charge

Real Estate Development

Recreational Activities of Others for a Charge

Rent-A-Garden

Roadside Stands

Soil Sampling

Tree (Christmas) Sales

U-Cut Tree Farms

U-Pick Farms

Other Non-Farming Activities for a Charge

Signature

NOTICE OF INSURANCE INFORMATION PRACTICES – PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A

CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS

APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER

PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUT AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED

TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER

YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE 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 MATERIAL FALSE INFORMATION, OR CONCEALS FOR

THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO MAY BE GUILTY OF COMMITTING A

FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND SUBJECTING THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL]

PENALTIES AS DEFINED BY YOUR STATE. THIS APPLICATION AND OTHER UNDERWRITING DOCUMENTS BECOME A PART OF YOUR

POLICY AND THE UNDERSIGNED UNDERSTANDS AND AGREES THAT HE/SHE WILL BE HELD RESPONSIBLE FOR ANY KNOWING

MISSTATEMENTS OR MISREPRESENTATION IN THE ANSWERS CONTAINED IN THIS DOCUMENT AND THAT INSURANCE BENEFITS MAY

BE DENIED.

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 OR HER KNOWLEDGE.

IN 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 MATERIAL

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 MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL

PENALTIES.

Applicant’s Signature Date Agent’s Signature Date

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Completed 11 August 2021

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