Fillable Farm and Ranch Owners Application (Standard Lines Services)

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Farm and Ranch Owners Application (Standard Lines Services)

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Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 1
Farm and Ranch Owners Application
Agency Information:
Agency Name: Agency Code:
Producer Name: Producer Phone:
Producer Email: Producer Fax:
Applicant Information:
Applicant Name:
Mailing Address: City:
Address Line 2 State: Zip:
Legal Entity: ☐ Individual ☐ Partnership ☐ Corporation ☐ Joint Venture ☐ Other Yr. Business Started:
Effective Date: Date Purchased: FEIN#:
Phone Number: Web Address:
Description of Operations:
# of Cattle: # of Horses: Type of Crop or Ranch:
Primary Location # 1:
Number of Acres: Is this location rented or leased to others? ☐Y ☐N
Address (911 address or nearest road/intersection):
City: State: Zip: County:
Is location outside city limits? ☐ Yes ☐ No
Miles from Nearest Fire Station:
If no 911 address available, please complete the next two lines.
Number of miles from closest town:
Direction from closest town: ☐N ☐S ☐ E ☐ W
Section: Range: Township:
Comments:
Additional Locations:
Loc #
# of
Acres
911 Address or
Section/Range/Township
Miles from
Town
Direction City
Zip
Code
Rented to
Others Y/N
Buildings
Y/N
2
3
4
5
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 2
Coverages and Limits: Please select all coverages that apply to this risk.
☐ Coverage A – Dwellings and Residential Structures
☐ Coverage C – Personal Property (household contents)
☐ Coverage E – Equipment, Grain, Hay or Livestock
☐ Coverage G – Barns, Storage Tanks, Silos or Fences
☐ Coverage H – Liability Occurrence Limit: ☐ $100,000 ☐ $300,000 ☐ $500,000 ☐ $1,000,000
☐ Coverage I – Liability Aggregate Limit: ☐ Same as Occurrence ☐ Double Occurrence
☐ Coverage J – Medical Payment – per person: ☐ $1,000 ☐ $3,000 ☐ $5,000 ☐ $10,000
Optional Endorsements:
☐ Earthquake (FP1040): Which Dwellings?
☐ Farm Computer Coverage (FP0408): Limit: $
☐ Hunting and Fishing Liability (CLFL0101): Receipts: $
☐ Scheduled Glass only (FP0467): Attach schedule with sizes
☐ Scheduled Personal Property (FP0461/0510): Jewelry, fur, silver, firearms (attach schedule – max total limit $100,000)
☐ Increased Special Limits (FP0407): $________ Jewelry ($6,500 Max) $________ Silverware ($10,000 Max)
$________ Firearms ($6,500 Max) $________ Money ($1,000 Max) $________ Securities ($3,000 Max)
☐ Windstorm or Hail Exclusion (FP1015): Describe Items:
☐ Additional Residence Rented to Others (FL0406): Attach list with address
☐ Custom Farming (FL0469): ☐ Baling ☐ Planting ☐ Harvest ☐
Other
Amount of Receipts: $
If Custom Farming is checked above, please describe:
☐ Farm Employers Liability (FL0465/0467): $50,000 max limit Payroll: $
☐ All-Terrain Vehicle Liability (FL0474): (if >1, add in comments) Year, Make and Model:
☐ Watercraft Liability (FL0483): ☐ Inboard ☐ Outboard Hull Make:
Engine Size: HP Maximum Speed: MPH Length:
☐ Additional Insured: ☐ Property (FP0450) ☐ Liability (FL0450) Describe Interest:
Name: Address:
☐ Additional Insured: ☐ Property (FP0450) ☐ Liability (FL0450) Describe Interest:
Name: Address:
Comments:
Other Exposures:
☐ Business on Premises other than Farming/Ranching: Please describe.
☐ Exotic Wildlife: Please describe type of Exotic Wildlife.
☐ Recreational Use by Others (Please describe):
☐ Does applicant board, train or breed horses for others? ☐ Yes ☐ No
If yes, are Hold Harmless Agreements obtained: ☐ Yes ☐ No (if yes, attach copy of agreement)
If yes, are statutory equine warning signs posted and included in contract: ☐ Yes ☐ No
Comments:
(Requires Copy of Hold Harmless)
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 3
Dwelling #1: if more than two dwellings, please describe on last page.
Location Number: Occupancy: ☐ Owner ☐ Tenant/Employee ☐ Vacant
Primary Residence: ☐ Yes ☐ No If “No”, is there a full time Caretaker or employee on premise? ☐ Yes ☐ No
If fulltime Caretaker, please describe exactly where they live:
Dwelling Limit: $ Appurtenant Structures Limit: $
Personal Property Limit: $ Additional Living Expenses: $
Perils: ☐Basic ☐Broad ☐Special Year Built: Square Footage:
Dwelling Valuation: ☐Actual Cash Value (FP1210)
☐Replacement Cost
Contents Valuation: ☐Actual Cash Value
☐Replacement Cost (FP0436)
Dwelling Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000 Wind/Hail Deductible: ☐1% ☐2% ☐5% ☐ N/A
Construction Type: ☐Frame ☐Masonry ☐Non-Combustible ☐Fire Resistive ☐Mobile Home
Roof Type: ☐Asphalt Shingles ☐Concrete Tile/Clay ☐Metal* ☐Tar & Gravel ☐Wood ☐Other
*If metal roof is selected, the Cosmetic Roof Limitation will automatically be included. Roof Age:
Number of smoke alarms in dwelling? Enclosed Foundation: ☐Yes ☐No
Central Heat/AC: ☐Yes ☐No Secondary Heating System: ☐Portable ☐Other
If dwelling is greater than 40 years old, what year was the last update: Electrical Plumbing
Comments:
Dwelling #2: if more than two dwellings, please describe on last page.
Location Number: Occupancy: ☐ Owner ☐ Tenant/Employee ☐ Vacant
Primary Residence: ☐ Yes ☐ No If “No”, is there a full time Caretaker or employee on premise? ☐ Yes ☐ No
If fulltime Caretaker, please describe exactly where they live:
Dwelling Limit: $ Appurtenant Structures Limit: $
Personal Property Limit: $ Additional Living Expenses: $
Perils: ☐Basic ☐Broad ☐Special
Year Built: Square Footage:
Dwelling Valuation: ☐Actual Cash Value (FP1210)
☐Replacement Cost
Contents Valuation: ☐Actual Cash Value
☐Replacement Cost (FP0436)
Dwelling Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000 Wind/Hail Deductible: ☐1% ☐2% ☐5% ☐ N/A
Construction Type: ☐Frame ☐Masonry ☐Non-Combustible ☐Fire Resistive ☐Mobile Home
Roof Type: ☐Asphalt Shingles ☐Concrete Tile/Clay ☐Metal* ☐Tar & Gravel ☐Wood ☐Other
*If metal roof is selected, the Cosmetic Roof Limitation will automatically be included. Roof Age:
Number of smoke alarms in dwelling?
Enclosed Foundation: ☐Yes ☐No
Central Heat/AC: ☐Yes ☐No Secondary Heating System: ☐Portable ☐Other
If dwelling is greater than 40 years old, what year was the last update: Electrical Plumbing
Comments:
✔
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 4
Equipment, Grain, Hay and Livestock
☐ Grain
Limit in Metal Structures: $_______
Limit in Other Structures: $_______
Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000
Perils: ☐Basic ☐Broad
☐Special
☐ Hay or Straw
Limit in Structures: $__________
Limit in Open: $__________
Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000
Perils: Basic Only
☐ Scheduled Livestock
Head Count:______________
Value Per Head: $_________
Please describe:
Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000 Perils: ☐Basic ☐Broad
☐ Animal Collision
Head Count:______________
Value Per Head: $_________
Deductible: N/A Perils: Collision Only
☐ Miscellaneous Farm Equipment
$3,000 Max per item
Limit: $______________
Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000
Perils: ☐Basic ☐Broad
☐Special
☐ Borrowed/ Rented Farm Equipment
Limit: $______________
Deductible: ☐$500 ☐$1,000 ☐$2,500 ☐$5,000
Perils: ☐Basic ☐Broad
☐Special
Equipment Schedule: if more space is needed, please attach schedule
Location: Equipment Type: ☐Standard Farm Equipment ☐Harvesting, Irrigation & Excavating Equipment
Limit: $
Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000
Serial #:
Year: Make: Model: Item Description:
Location:
Equipment Type: ☐Standard Farm Equipment ☐Harvesting, Irrigation & Excavating Equipment
Limit: $ Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Serial #:
Year: Make: Model: Item Description:
Location:
Equipment Type: ☐Standard Farm Equipment ☐Harvesting, Irrigation & Excavating Equipment
Limit: $ Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Serial #:
Year: Make: Model: Item Description:
Location: Equipment Type: ☐Standard Farm Equipment ☐Harvesting, Irrigation & Excavating Equipment
Limit: $
Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000
Serial #:
Year: Make: Model: Item Description:
Location:
Equipment Type: ☐Standard Farm Equipment ☐Harvesting, Irrigation & Excavating Equipment
Limit: $ Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Serial #:
Year: Make: Model: Item Description:
Comments:
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 5
Barns, Tanks, Silos and Fences:
Location: ☐Barns, Stables and Outbuildings ☐Tanks ☐Silos ☐Fences, Corrals/Chutes ☐Windmills
Description:
Limit:
Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Perils: ☐Basic ☐Broad ☐Special
Construction: ☐Frame ☐Masonry ☐Non-Combustible ☐Fire Resistive
Yr. Blt: Sq. Ft:
Roof Type: ☐Asphalt Shingles ☐Concrete Tile ☐Metal* ☐Wood ☐All Other Roof Age:
*If metal roof is selected, the Cosmetic Roof Limitation will automatically be included.
Open Sides: ☐Yes ☐No Hay Storage: ☐Yes ☐No ☐ Exclude Vandalism
☐ Windstorm or Hail Exclusion – Direct Damage AL only ☐ Exclude Wind/Hail – AL, TX, MS only
Location:
☐Barns, Stables and Outbuildings ☐Tanks ☐Silos ☐Fences, Corrals/Chutes ☐Windmills
Description:
Limit:
Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Perils: ☐Basic ☐Broad ☐Special
Construction: ☐Frame ☐Masonry ☐Non-Combustible ☐Fire Resistive
Yr. Blt: Sq. Ft:
Roof Type: ☐Asphalt Shingles ☐Concrete Tile ☐Metal* ☐Wood ☐All Other
Roof Age:
*If metal roof is selected, the Cosmetic Roof Limitation will automatically be included.
Open Sides: ☐Yes ☐No Hay Storage: ☐Yes ☐No ☐ Exclude Vandalism
☐ Windstorm or Hail Exclusion – Direct Damage AL only ☐ Exclude Wind/Hail – AL, TX, MS only
Location: ☐Barns, Stables and Outbuildings ☐Tanks ☐Silos ☐Fences, Corrals/Chutes ☐Windmills
Description:
Limit: Deductible: ☐$500 ☐$1,000 ☐ $2,500 ☐$5,000 Perils: ☐Basic ☐Broad ☐Special
Construction: ☐Frame ☐Masonry ☐Non-Combustible ☐Fire Resistive Yr. Blt: Sq. Ft:
Roof Type: ☐Asphalt Shingles ☐Concrete Tile ☐Metal* ☐Wood ☐All Other Roof Age:
*If metal roof is selected, the Cosmetic Roof Limitation will automatically be included.
Open Sides: ☐Yes ☐No Hay Storage: ☐Yes ☐No ☐ Exclude Vandalism
☐ Windstorm or Hail Exclusion – Direct Damage AL only ☐ Exclude Wind/Hail – AL, TX, MS only
Comments:
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 6
Supplemental Heating Questionnaire
Dwelling #
Portable Unit? ☐Yes ☐No Permanently Installed? ☐Yes ☐No
What type of fuel? ☐Wood ☐Kerosene ☐Natural Gas ☐Oil ☐Electric ☐Other
Are proper clearances being maintained between the heating device and any combustible materials? ☐Yes ☐No
Is the stove and chimney pipe inspected and cleaned at least once a year? ☐Yes ☐No
USIG General Underwriting Information
How long have you known the applicant: yrs.
Applicant is ☐Married ☐Divorced ☐Widowed ☐Single
Agriculture is applicant’s occupation. ☐Primary ☐Secondary ☐Only
What is applicant’s primary occupation?
Is this new business to your agency? ☐Yes ☐No
Farmed/Ranched by: ☐Owner ☐Tenant ☐Manager ☐Other
For locations leased or rented to others:
What are tenant operations:
Are Certifications of Liability provided? ☐Yes ☐No Limit: $
Has coverage ever been cancelled or non-renewed? ☐Yes ☐No
Reason:
Does applicant have any other policies with USIG? ☐Yes ☐No If yes, please list:
Comments:
USIG Property and Liability Information
When did the agent last see the property?
Are there fire extinguishers on site? ☐Yes ☐No
Are dwellings equipped with a monitored burglar or fire alarm? ☐Yes ☐No Company?
Are livestock fenced? ☐Yes ☐No
Is there a swimming pool? ☐Yes ☐No Is pool area adequately fenced? ☐Yes ☐No
Is there a pond or lake used for recreational activities? ☐Yes ☐No If yes, please describe:
Does the applicant own, rent or maintain any other property? ☐Yes ☐No If Yes, please describe:
Are any buildings located in a flood plane? ☐Yes ☐No If yes, please describe:
Are labor services, migrant workers or independent contractors used for labor on premises? ☐Yes ☐No
If yes, describe activities performed by those workers:
If yes, are certificates of Workers Compensation required? ☐Yes ☐No
Does applicant provide housing for migrant labor or independent contractors? ☐Yes ☐No
If yes, does housing include smoke alarms and fire extinguishers? ☐Yes ☐No
Are there any unusual hazards present such as quarries, commercial wood lot, open dump pits, sump holes, vehicle trails,
reservoirs, etc.? ☐Yes ☐No If yes, please describe:
Are Farm operations open to the public, such as U-Pick, Community Gardens, auction sales, swap meets, sales or
food/beverage service? ☐Yes ☐No If yes, please describe:
Does applicant sell any product (their own or anyone else’s) such as seed, feed, fertilizers, herbicides, pesticides, chemicals,
etc.? ☐Yes ☐No If yes, please describe:
Is applicant licensed for application of chemicals? ☐Yes ☐No
If yes, provide license number and expiration date:
Are there children in the household under the age of 25? ☐Yes ☐No If yes, please list age(s):
Comments:
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 7
USIG Property and Liability Information Continued
Are there any dogs on the premises? ☐Yes ☐No
If yes, please list number of dogs and breeds: _________________________________________
If yes, have the pets been involved in any prior claims: ☐Yes ☐No
Are there any Arena, Roping or Rodeo practice facilities on premises? ☐Yes ☐No
If yes, please describe:
Any livestock provided to rodeo facilities? ☐Yes ☐No If yes, please describe:
Any ATVs or Recreational Equipment used? ☐Yes ☐No If yes, describe usage:
Does applicant have crop maze, provide tours, offer hay rides or make premises available for trail rides? ☐Yes ☐No
If yes, please describe:
Are any contract or service operations performed for others such as tilling, excavating, chemical spraying, trenching, custom
farming, etc.? (If Custom Farming is desired, please select in Optional Endorsements section). ☐Yes ☐No
If yes, please describe:
If produce is grown, are precautions made to reduce food borne illnesses?: ☐Yes ☐No ☐N/A
Comments:
Additional Interests:
Mortgagee: Loss Payee:
Address: Address:
Address: Address:
City/State/Zip: City/State/Zip:
Interest: Interest:
Comments:
Prior Losses:
Claim Date: Loss Amount: $ Details:
Claim Date: Loss Amount: $ Details:
Claim Date: Loss Amount: $ Details:
Comments:
Prior Carriers:
Prior Carrier Name: Expiring Premium:
Billing Information:
Billing Method: ☐Agency Bill ☐Direct Bill
Payment Plan: ☐1-Pay (100% down, no service fees) ☐ 2-Pay (50% down + 1 installment)
☐3-Pay (33% down + 2 installments) ☐4-Pay (25% Down + 3 installments) ☐9-
Pay (25% down + 8 installments)
☐10-Pay (10% down + 9 installments) ☐10-Pay (20% down + 9 installments) ☐11-Pay (20% down + 10 installments)
Down Payment: $
Union Standard Insurance Group on behalf of Acadia Insurance Company • Continental Western Insurance Company • Firemen’s Insurance
Company of Washington, D.C. • Union Insurance Company • Union Standard Lloyds. Refer to the policy for the applicable insurer, each of
which has sole financial responsibility for its own products and services. (08/2013)
Page 8
Additional Comments and Information:
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Farm and Ranch Owners Application (Standard Lines Services)

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Completed 7 February 2021

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