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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

□

Date

Agent'sSignature

Date

Page8of8

AnimalBoarding

Lodging

(Bed&Breakfast)foraCharge

AuctionsorSales

5.AnyoftheFollowing?

RealEstateDevelopment

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

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

Livestock(orOther)Feed

Feed,Seed,Grain,Fertilizer,Chemicals,Additives

OtherFarmorNonFarmProductsonoroffPremises

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

IndicateiftheInsuredDoesAnyofTheseActivities ExplainAllYESReponses

Dairy‐ProcessingofMilkorMilkProducts

Dairy‐SaleofRawMilkorMilkProductstothePublic

2.LivestockSlaughter,ButcherorOtherwisePrepareany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

OtherNonFarmingActivitiesforaCharge

Remarks:

Tree(Christmas)Sales

U‐CutTreeFarms

RecreationalActivitiesofOthersforaCharge

Rent‐A‐Garden

RoadsideStands

SoilSamplingorAnalysisService

U‐PickFarms

Applicant's

Signature

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OUR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

ATHIRDPARTYINCONNECTIONWITHTHEDEVELOPMENTOFYOURSCORE.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,FL,HI,MA,NE,OH,OK,

ORorVT;inDC,LA,ME,TN,VAandWA,insurancebenefitsmayalsobedenied). ALL OTHER DOCUMENTS AND INFORMATION REQUIRED BY UNDERWRITING BECOME A PART OF

YOUR POLICY APPLICATION.

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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MAYSUBJECTTHEPERSONTOCRIMINALANDCIVILPENALTIES.

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.

JAIB Appl 002 0412

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Completed 11 August 2021

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