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FARM & RANCH SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
Please attach: A copy of all lease agreements and waivers (hunting and farming if available).
Applicant’s Name:
Street Address:
Mailing Address (if different):
City, State, Zip:
Location description (Parcel, Block, Lot, etc. Information sufficient to identify the location of the property):
Website:
Years under current ownership:
Years under current name:
Total number of employees: Full Time_______________ Part Time_______________
1. Please provide the following information for the next 12 months:
Description of operations or services Gross revenue
Auctioneering
Cabin/Campground/Vacation Rentals
Christmas Tree Farm/Pumpkin Patches
Custom Farming
Food Sales
Garden/Nursery Sales Including Pick-it-Yourself
Hunting on Insured’s Premises- First and Third Parties
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
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Rental of Land, Structures for Business, Habitational or
farm/ranch uses
Saddle Animal rental
Vineyard/Winery
Slaughtering or butchering for others for a fee
Feed lots or feed yard
Other: (please describe)
2. Please complete the following exposure information for the next 12 months:
Description of operations or services Number of Units
Land (total acres)
Livestock- total number of head
Poultry and Birds
Dwellings- Owner Occupied, Vacant, Rental Dwellings
Bunkhouses
Lakes, Ponds, Reservoirs (indicate acreage)
Boats (no power): #
Boats with motors/engines) #
ATVs
Swimming Pools
Wind Turbines/Solar Panels
Oil or Gas Facilities- Operated by 3
rd
parties
3. Please complete the following exposure information for the next 12 months:
Breakdown of Land and Use Number of Acres
Machine Harvested Crops
Vegetable Crops
Nursery/Greenhouse Production
Vineyards
Groves or Orchards
Standing Timber
Pasture
Aquaculture
1. Do you check MVR’s for all drivers prior to allowing use of your vehicles? Yes No
2. How often are MVR’s rechecked?
3. Do you have a formal vehicle maintenance program? Yes No
4. How often is maintenance performed?
DRIVER AND VEHICLE/ATV SAFETY INFORMATION
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5. Are any repairs performed in house? Yes No
If yes, please describe:
6. Are ATV’s used on the property? Yes No
If yes, please describe vehicles, use, and who has access to vehicles: ___________________________________
__________________________________________________________________________________________________
7. Do your employees use their personal vehicles completing their job duties? Yes No
If yes, please describe: ________________________________________________________________________
__________________________________________________________________________________________________
8. Do you hire or rent any motor vehicles for short periods of time (rentals, not long term leases)? Yes No
If yes, please describe: ________________________________________________________________________
__________________________________________________________________________________________________
GENERA
L INFORMATION river and Vehicle/ATV Safety Information
1. Do you permit hunting, fishing, or other sporting or recreational activities? Yes No
Describe:
a. Is a fee charged? Yes No
2. Are guests that use the property for hunting and similar activities required to sign waivers? Yes No
3. Do you provide saddle animal rental? Yes No
4. If yes, do you require waivers from all participants? Yes No
5. Do you board animals for other on your premises? Yes No
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND
WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for
insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material
thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit
is a crime punishable by fines or imprisonment, or both.
HUNTING AND SADDLE ANIMAL
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NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for
each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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 Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of
any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon
such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application
and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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