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Farmowners Quote
Form: Farmowners Insurance Quote
Farmowners Insurance Quote
Contact Information
Full Name:
Street Address:
City, State & Zip:
E-Mail Address:
Day Telephone:
Fax:
Eve Telephone:
Best Time To Reach You:
Select
Mornings
Afternoons
Evenings
Weekends
Anytime
Date of Birth:
Current Insurance Information
Insurance Company Name:
(
NOT
Insurance Agency/Broker)
Policy Exp. Date:
Amount Insured for:
Premium Amt:
Any Claims in Last 3 years?
General Information About Your Home
Year Home Built:
Total Square Feet:
Yrs @ present address:
Market Value of Home: $
Liability Coverage:
Please Select
$100,000
$300,000
$500,000
$1,000,000
Other
Deductible Desired:
Please Select
$250
$500
$1000
$2500
$5000
Distance to nearest fire hydrant:
Please select
Less than 1,000 ft
More than 1,000 ft
Distance to nearest fire department:
Please select
Less than 5 miles
More than 5 miles
Name of Responding Fire Dept:
Home Type:
Select
1 story
1 1/2 story
2 story
Split level
Bi-Level
Other
Home Construction:
Select
Frame
Brick
Masonry
Other
Roof Type:
Garage Type:
Select
1 car
2 car
3 car
Car Port
Other
Age of roof:
Garage:
Select
Attached
Detached
Basement
Other
# of Bedrooms:
# of Fireplaces:
# of Bathrooms:
Exterior:
Select
Deck
Porch
Patio
Screen Patio
Foundation:
Select
Slab
Crawl
Basement
Pier & Post
Not Sure
Other List in Comments
Basement Finished?
No
Yes
Number of Acres:
If finished, what %?
%
Farm Information
Type of Farming Operation:
Total Acres by Crop:
Crop
Acres
Amount of Insurance on all Farm Buildings (including silos):
Amount of Insurance on Farm Equipment and Machinery (include tractors, milk equipment, crop dryer, etc...)
Amount of Insurance on all Livestock:
Annual Revenues from Custom Farm Work:
Number of Horses:
Number of Cows:
Additional Information
Swimming Pool?:
No
Yes
Pool Fenced:
No
Yes
Diving Board:
No
Yes
Trampoline:
No
Yes
Smoke Detector:
No
Yes
Security System:
None
Monitored
Non-Monitored
Heating System:
Select
Electric
Gas
Oil
Propane
Other
Heated Sq. Ft.
Central Air/Heat:
Select
Yes
No
Updates: (check all that apply)
Wiring updated
Plumbing updated
Heating updated
Fire Alarm:
None
Monitored
Non-Monitored
Replacement cost of personal items:
Any business conducted in home:
List values of any jewelry, furs, or specialty items:
List pets & breeds:
Do you want to include a Flood Insurance Quote?:
No
Yes
Additional Comments
Please give any additional comments or questions
No coverage of any kind is bound or implied by submitting information via this online form
Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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