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Farmranch Allianz 01 (Risk Placement Services, Inc.)

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Page 1 of 10
Farm and Ranch Application
AGRICULTURE APPLICATION
APPLICANT INFORMATION SECTION
DATE
AGENCY
INSURING COMPANY
AGENCY CODE
NEW
RNWL
EFFECTIVE DATE
EXPIRATION DATE
POLICY NUMBER
PRODUCING AGENT QUOTE ISSUE POLICY
First Name : BOUND MULTIGARD COMBINATION POLICY
Last Name : FARM AND RANCH BASIC POLICY
INDICATE SECTIONS ATTACHED
PROPERTY COMMERCIAL GENERAL LIABILITY
SCHEDULED/UNSCHEDULED
AUTO
AGRI-PERSONAL PROPERTY
AGRI-BUSINESS LIABILITY UMBRELLA / EXCESS
APPLICATION INFORMATION
NAME (First Named Insured and Other Named Insureds) MAILING ADDRESS (of First Named Insured)
ENTITY TYPE: YEARS IN THIS BUS FEDERAL ID# / SSN SAFETY INSPECTION CONTACT PHONE
TYPE OF FARM/RANCH (Description of Operations) HOBBY FARM? YES
NO
SIC
ADDITIONAL APPLICANT INFORMATION
GLOBAL PROPERTY DEDUCTIBLE: WIND / HAIL DEDUCTIBLE:
DOES APPLICANT HAVE ANY OTHER BUSINESS? (IF YES, DESCRIBE)
YES IS BUSINESS NEW TO AGENCY? YES
NO
NO
Agent’s Last Inspection Date:
LOSS HISTORY (Include currently valued Loss Runs for the past 5 years) LOSS RUNS ATTACHED
Date of Loss Total Incurred Open/Closed Description of Loss
PRIOR INSURANCE INFORMATION
Prior Carrier Policy # Policy Term Premium
HAS ANY POLICY BEEN CANCELLED OR NONRENEWED IN THE PAST 5 YEARS? IF YES, EXPLAIN. (NOT APPLICABLE IN MO) YES
NO
Page 2 of 10
DISCONTINUED FARMING OPERATIONS
TERRORISM COVERAGE
Terrorism Accepted.
Exclusion of Terrorism involving Nuclear, Biological or Chemical Terrorism applies.
SUPPLEMENTALS REQUIRED:
Dwellings over 40 years old – Older Dwelling Questionnaire
Equine Exposures – Equine Supplemental / Equine CC Liability
Dairy Operations – Dairy Questionnaire
Wood Stove – Wood Stove Questionnaire
Poultry Operations – Poultry Questionnaire
Hunting or Fishing on the Premises – Hunting / Fishing Questionnaire
If Swimming Pool Present – Swimming Pool Questionnaire
If Trampoline Present – Trampoline Questionnaire
NOTICE OF INSURANCE INFORMATION PRACTICES
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS
OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER
PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD
PARTIES. 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 INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
COPY OF NOTICE OF INFORMATION PRACTICES (Privacy) HAS BEEN GIVEN TO THE APPLICANT (Not applicable in all states)
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, HI,
NE, OH, OK, OR, or VT; in DC, LA, ME and VA, insurance benefits may also be denied.)
AGENT ACKNOWLEDGES AND AFFIRMS THAT THE AGENT HAS REVIEWED ALL OF THE QUESTIONS IN ALL OF THE QUESTIONNAIRES,
AND THAT SAID AGENT HAS REVIEWED ALL OF THE QUESTIONS WITH THE INSURED OR PROSPECTIVE INSURED AND ALL APPLICABLE
QUESTIONS HAVE BEEN ANSWERED IN FULL.
APPLICANTS
DATE
SIGNATURE
PRODUCERS
DATE
SIGNATURE
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Page 3 of 10
LOCATION INFORMATION
LOC #
BLD
STREET, CITY, COUNTY, STATE, ZIP CODE (Include
route, section, township range, etc. if necessary)
PROT
CLASS
# ACRES
TOTAL
INSIDE CITY
LIMITS
LEASED OR
OWNED BY
GROSS
RECEIPTS
Page 4 of 10
DWELLING INFORMATION
*Older Dwelling Questionnaires due on dwellings in excess of 40 years of age
LOCATION NO.
STREET, CITY, COUNTY, STATE, ZIP CODE
(Include route, section, township, range, etc.)
FIRE DISTRICT NAME
FARM NAME
OCCUPANT
DISTANCE TO
HYDRANT
FIRESTATION
DESCRIPTION
OF PROPERTY
YR BLT
SQ FT
ROOF TYPE
NAME OF
OCCUPANT
DEDUCTIBLE
LIMIT OF
INSURANCE
ROOF YEAR
CONSTRUCTION
Frame
Masonry
Non-combustible
Fire resistive
Log
CAUSE OF
LOSS
Basic
Broad
Special-Broad
Special
LOSS
VALUATION
ACV
RC
SUPPLEMENTAL
HEATING
DEVICE?
YES
NO
CENTRAL AIR?
(Or protection devices
in lieu of central air)
YES
NO
TYPE 1 TYPE 3
TYPE 2
MOBILEHOME?
YES
NO
WIND / HAIL
DEDCUTIBLE
EXTENDED
REPLACEMENT
COST
YES
NO
LOCATION NO.
STREET, CITY, COUNTY, STATE, ZIP CODE
(Include route, section, township, range, etc.)
FIRE DISTRICT NAME
FARM NAME
OCCUPANT
DISTANCE TO
HYDRANT
FIRESTATION
DESCRIPTION
OF PROPERTY
YR BLT
SQ FT
ROOF TYPE
NAME OF
OCCUPANT
DEDUCTIBLE
LIMIT OF
INSURANCE
ROOF YEAR
CONSTRUCTION
Frame
Masonry
Non-combustible
Fire resistive
Log
CAUSE OF
LOSS
Basic
Broad
Special-Broad
Special
LOSS
VALUATION
ACV
RC
SUPPLEMENTAL
HEATING
DEVICE?
YES
NO
CENTRAL AIR?
(Or protection devices
in lieu of central air)
YES
NO
TYPE 1 TYPE 3
TYPE 2
MOBILEHOME?
YES
NO
WIND / HAIL
DEDCUTIBLE
EXTENDED
REPLACEMENT
COST
YES
NO
LOCATION NO.
STREET, CITY, COUNTY, STATE, ZIP CODE
(Include route, section, township, range, etc.)
FIRE DISTRICT NAME
FARM NAME
OCCUPANT
DISTANCE TO
HYDRANT
FIRESTATION
DESCRIPTION
OF PROPERTY
YR BLT
SQ FT
ROOF TYPE
NAME OF
OCCUPANT
DEDUCTIBLE
LIMIT OF
INSURANCE
ROOF YEAR
CONSTRUCTION
Frame
Masonry
Non-combustible
Fire resistive
Log
CAUSE OF
LOSS
Basic
Broad
Special-Broad
Special
LOSS
VALUATION
ACV
RC
SUPPLEMENTAL
HEATING
DEVICE?
YES
NO
CENTRAL AIR?
(Or protection devices
in lieu of central air)
YES
NO
TYPE 1 TYPE 3
TYPE 2
MOBILEHOME?
YES
NO
WIND / HAIL
DEDUCTIBLE
EXTENDED
REPLACEMENT
COST
YES
NO
Page 5 of 10
COVERAGE G – BARNS AND OUTBUILDINGS
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
LOCATION NO.
TYPE
YR
BLT
ROOF YEAR
& TYPE
CONSTRUCTION
VAL
CAUSE OF LOSS
DEDUCTIBLE
LIMIT OF
INSURANCE
DESCRIPTION OF PROPERTY
FULLY ENCLOSED? YES
NO
Frame
Masonry
Non-combustible
Fire resistive
Log
ACV
RC
Basic
Broad
Special-Broad
Special
Page 6 of 10
SCHEDULED FARM PERSONAL PROPERTY
1. IS ANY PROPERTY KEPT ON A LOCATION(S) OTHER THAT AN INSURED LOCATION?
YES
NO
2. WHAT IS RADIUS OF OPERATIONS OF EQUIPMENT?
MILES
3. IS EQUIPMENT WELL MAINTAINED?
YES
NO
COVERAGE E - SCHEDULED FARM PERSONAL PROPERTY
DESCRIPTION
VIN / SERIAL NUMBER
CAUSE
OF
LOSS
VAL.
DED.
YEAR
LIMIT
Scheduled Farm Personal Property Total: $
COVERAGE F - UNSCHEDULED FARM PERSONAL PROPERTY (Inventory must be on file with the company)
TYPE
(Tractor / Combine, Cotton Pickers, Misc Farm
Implements, Tools, Supplies, Equipment)
DESCRIPTION
CAUSE OF
LOSS
DEDUCTIBLE
LIMIT
Unscheduled Farm Personal Property Total: $
Page 7 of 10
GENERAL INFORMATION
1. DOES THE APPLICANT DIRECTLY SUPERVISE THE FARM? YES
NO
2. ARE ANY WOOD OR COAL FIRED STOVES USED IN ANY BUILDINGS? YES
NO *If yes questionnaire is required
3. SHOW POLICY NUMBER(S) OF OTHER INSURANCE WITH FFIC.
Type of Insurance Policy Number Insured Name
4. IS ENTIRE PREMISES OCCUPIED YEAR ROUND? YES
NO
5. DURING THE LAST FIVE YEARS, HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED
YES
OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER
ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?
NO
AGRICULTURE LIABILITY SECTION
Personal Liability Farm Liability Farm CGL
COVERAGES
LIMIT OF LIABILITY
BODILY INJURY AND PROPERTY DAMAGE LIABILITY
PERSONAL AND ADVERTISING INJURY LIABILITY
MEDICAL PAYMENTS TO OTHERS
FIRE DAMAGE LIMIT
TOTAL ACRES:
EXCLUDE PRODUCTS COVERAGE YES NO
Products NOC Recipts:
OWNER OPERATED YES NO
TOTAL NUMBER OF DWELLINGS
NUMBER OF OWNER OCCUPIED
DWELLINGS
1 FAMILY: 2 FAMILY:
NUMBER RENTAL / TENANT DWELLINGS OR
BUNKHOUSE
1 FAMILY: 2 FAMILY: BUNKHOUSE:
DO YOU PERFORM ANY SPECIFIC PLANTING, HARVESTING, OR SIMILAR FARMING OPERATIONS FOR OTHERS, UNDER
THEIR DIRECTION AT A LOCATION OTHER THAN YOUR OWN FARM PREMISES?
YES NO
Page 8 of 10
GENERAL INFORMATION
EXPLAIN ALL 'YES' RESPONSES YES NO
EXPLAIN ALL 'YES' RESPONSES YES NO
1. ARE INDEPENDENT CONTRACTORS HIRED TO PERFORM ANY
FARMING OPERATIONS?
17. IS THERE A SWIMMING POOL ON ANY INSURED PREMISES?
*IF YES COMPLETE POOL SUPPLEMENTAL
2. IS ANY PART OF THE FARM USED OR LEASED FOR
ORGANIZED
RECREATIONAL USE?
18. IS ANY LAND HELD FOR REAL ESTATE DEVELOPMENT OR
SPECULATION?
3. DOES APPLICANT BUILD, REPAIR OR DESIGN MACHINERY,
EQUIPMENT OR SYSTEMS FOR ANYONE AT A CHARGE OR FEE?
19. DOES APPLICANT MAINTAIN A NON-FARM OFFICE OR
PRIVATE SCHOOL IN AN INSURED BUILDING?
4. DOES APPLICANT MIX, PROCESS, SLAUGHTER, BUTCHER OR
OTHERWISE PREPARE FOR ANY 'END CONSUMER' HIS OR ANY
OTHER GROWER'S PRODUCT?
20. DOES APPLICANT SERVE ON ANY BOARDS FOR
REMUNERATION?
5. DOES APPLICANT HANDLE ANY PRODUCT, SUCH AS SEED,
FERTILIZER, SPRAYS, ETC. FOR RESALE?
21. IS THE APPLICANT A SUBSIDIARY OF ANOTHER OR DOES
THE APPLICANT HAS SUBSIDIARIES?
6. ARE ANY CONTRACT OR SERVICE OPERATIONS PERFORMED
FOR OTHERS SUCH AS SNOW REMOVAL, TILING, EXCAVATING
OR DITCHING?
22. IS A FORMAL SAFETY PROGRAM IN EXISTENCE?
7. ARE THE FARM PREMISES OPEN TO THE PUBLIC FOR
ACTIVITIES SUCH AS ROADSIDE STANDS, 'U-PICK',
RECREATIONAL, 'RENT-A-GARDEN', AUCTION, SALES, SHOW,
FOOD, OR BEVERAGE SERVICE, HAY RIDES, FISHING,
KENNELS, ANIMAL BOARDING, OR CHRISTMAS TREE SALES
USES?
23. IF LIVESTOCK IS KEPT, ARE PREMISES IN AN OPEN RANGE
AREA?
8. ANY NON-FARM PRODUCTS MANUFACTURED OR SOLD FROM
ANY INSURED LOCATION?
24. IF LIVESTOCK IS KEPT, ARE PREMISES IN CLOSED RANGE
AREA?
9. DOES THE APPLICANT PROVIDE A SERVICE OF CROP
DRYING, DEHYDRATING OR PACKING FOR OTHERS?
25. ANY NON-OWNED HORSES ON ANY INSURED PREMISES?
*IF YES COMPLETE EQUINE SUPPLEMENTAL
10. ARE ANY PORTIONS OF THE FARM RENTED OR LEASED OR
USED BY ANY OTHER INDIVIDUAL, CORPORATION OR INTEREST
FOR OTHER THAN FARMING?
26. DOES INSURED BOARD, RACE, BREED OR RENT HORSES?
*IF YES COMPLETE EQUINE SUPPLEMENTAL
11. 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?
*IF YES COMPLETE TRAMPOLINE SUPPLEMENTAL
27. DOES APPLICANT HAVE ANY POTENTIALLY DANGEROUS
ANIMALS OR EXOTIC PETS?
12. DOES THE APPLICANT ALLOW OTHERS TO DISPOSE OF
WASTE MATERIALS ON THE PREMISES?
28. 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.
13. IS THERE AN AIRSTRIP ON THE PREMISES?
29. ARE ANY PREMISES USED FOR HUNTING PURPOSES FOR A
FEE OR CHARGE?
*IF YES COMPLETE HUNTING AND FISHING SUPPLEMETAL
14. ARE ANY 'HOLD HARMLESS' OR
'INDEMNIFYING'AGREEMENTS IN EFFECT?
30. DOES INSURED DO THEIR OWN APPLICATION OF
CHEMICALS?
15. OTHER THAN THE DESCRIBED INSURED PREMISES ARE
THERE ANY OTHER PREMISES WHICH THE APPLICANT OR
SPOUSE OWNS, RENTS OR OPERATES AS A FARM OR RANCH,
OR MAINTAINS AS A RESIDENCE, OTHER THAN BUSINESS
PROPERTY?
31. DOES INSURED DO ANY APPLICATION OF CHEMICALS FOR
HIRE FOR OTHERS?
32. 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?
33. HAS THE INSURED BEEN SUED OR HAD ANY AGRICULTURAL
CHEMICAL DRIFT LOSSES IN THE PAST FIVE YEARS?
34. DOES INSURED TRANSPORT CHEMICALS FROM CHEMICAL
DISTRIBUTION OUTLETS?
16. DOES APPLICANT MAINTAIN ANY VACATION OR SEASONAL
PREMISES?
35. HAS APPLICANT EVER HAD ANY COMPLAINTS REGARDING
POLLUTION, WASTE RUNOFF OR SIMILAR DAMAGES?
REMARKS
Page 9 of 10
RECREATIONAL VEHICLES
(Watercrafts, Sailboats, RVs, Snowmobiles, ATVs, UTVs)
LIAB.
COV.
PD
COV.
TYPE
DESCRIPTION (Year / Make & Model)
ENGINE
SIZE / CC
LENGTH
(Watercraft)
PD
LIMIT
PD
DEDUC.
SCHEDULED NON-FARM PERSONAL PROPERTY (Jewelry, Firearms, Fine Arts, Stamps, Coins, etc…)
CATEGORY
DESCRIPTION
VALUE
ADDITIONAL INTERESTS (Mortgagee, Loss Payee, Additional Insured)
NAME
ADDRESS
INTEREST TYPE
ASSOCIATION (Location # & Building #)
PAYMENT INFORMATION
FULL PAY FOUR PAY TEN PAY
TWO PAY SIX PAY
PAYOR NAME
BILLING ADDRESS
Page 10 of 10
ADDITIONAL COVERAGES, RESTRICTIONS, & ENDORSEMENTS
Multigard Farm & Ranch Agricover for Liability (CGL) FL 8418
Multigard Farm & Ranch Agricover for Property FP 7481
Farm Property Endorsement Additional Coverage Pollutant Clean Up and Removal Expenses Coverage FP 7422
Limit:
Farm Employers Liability & Farm Employees Medical Payments Information FL 0465
Limit: Medical Payments: Annual Payroll: # of Employees:
Animal Collision FP 7456
Type of Livestock: Number of Head: Limit: $500 $1,000 $2,000
Increased Limits of Jewelry, Watches, & Furs FP 0407
Equipment Breakdown Coverage FP 7472
Additional Personal Liability
(Individuals living on premises full time in owner/family occupied dwellings; not already included in Named Insured)
Name: Insurable Interest:
Name: Insurable Interest:
Name: Insurable Interest:
Custom Farming Liability Coverage FL 0469
*Complete Farm Management / Custom Farming Supplemental
Type of Custom Farming: Receipts:
Windstorm or Hail Percentage Deductible FP 0305
Disruption of Farm Operations FP 1501
Location #: Description of Property: Limit of Insurance:
Peak Season FP 1229
Extended Property Coverage for Orchard and Vineyard Growers FP 7404
Extended Property Coverage for Dairy Operations FP 7409
Extended Replacement Cost FP7435
Equine Coverage Form – Breeding, Training, Boarding Operations FL 8493
*Complete Equine Supplemental
OTHER
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Completed 30 July 2020

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