Fillable Limited Agricultural Chemical Drift Supplemental Questionnaire (Risk Placement Services, Inc.)

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Limited Agricultural Chemical Drift Supplemental Questionnaire (Risk Placement Services, Inc.)

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Limited Agricultural Chemical Drift Supplemental Questionnaire
Named Insured:
Policy Number:
Agency:
In order for Fireman's Fund Insurance Company to consider providing this coverage,
please complete the following questions:
1. Does the insured do their own application of chemicals? ………………………..
Yes No
2. Does the insured do any application of chemicals for hire for others? ………….
Yes No
3. Are there any public parks, golf courses, schools, churches, stores, subdivisions,
towns/cities or any other public exposures neighboring any of the insured’s farm
locations? …….. Yes No
4. Has the insured been sued or had any agricultural chemical drift losses in the past
five years? ……. Yes No
5. Does the insured transport chemicals from the chemical distribution outlets? …….
Yes No
Ed. 10/2004
Explain all “Yes” responses:
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Limited Agricultural Chemical Drift Supplemental Questionnaire (Risk Placement Services, Inc.)

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Completed 30 July 2020

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