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Farm and Ranch Questionnaire - Page 1

The following questionnaire consists of four (4) sections:

Primary Contact & Homeowner Information
Claims Information, Farm Premises, and Farm & Ranch Equipment
Other Locations/Acreage and Ranch Property
Auto Information

In order to serve you better, we ask that you provide as much information as possible.

The questionnaire should take 15-20 minutes to complete. To begin, please enter the Requested Effective Date and then click the "Next Page" button below.

Requested Effective Date:

Farm and Ranch Questionnaire - Page 2

PRIMARY CONTACT INFORMATION

First Name:

Last Name:

Telephone Number:

Date of Birth:

Email Address:

HOMEOWNER INFORMATION

Street Address:

City:

State:

Postal (Zip) Code:

Property Information

Year Home Built:

Square Footage:

Number of Stories:

Number of Bedrooms:

Number of Bathrooms:

Garage Type:

Attached
Detached

Garage Type:

Roof Type:

Age of Roof (in years):

Security System:

YESNO

Amount of Coverage:

Construction Type:

Prior Address:

Farm and Ranch Questionnaire - Page 3

CLAIMS INFORMATION

Enter claims (if any) that occurred in the past three (3) years on you current or prior home. Click "Add another response" to insert additional claims.

Date of Claim:

Description:

FARM PREMISES

Type of Operation:

Number of Livestock

Cattle:

Horse:

Goat:

Fuel Supply:

Water Supply:

Fenced?

YESNO

Fence Type:

Annual Income of Ranch Operation:

ATVs:

FARM & RANCH EQUIPMENT

Click "Add another response" to insert additional equipment.

Description:

Make:

Model:

VIN:

Farm and Ranch Questionnaire - Page 4

OTHER LOCATIONS/ACREAGE

Click "Add another response" to insert additional locations.

Other Location Information

Number of Premises:

Number of Acres:

Location (Road Number, Distance):

Type of Operations:

Leased to Others?

YESNO

Buildings?

Fenced?

YESNO

Type of Fence:

RANCH PROPERTY

Click "Add another response" to insert additional ranch properties.

Ranch Location Information

Building Number:

Number of Stories:

Year Built:

Square Footage:

Construction Type:

Use:

Owner/Tenant?

OWNERTENANT

Roof Type:

Edit section title

Age of Roof (In Years):

Open Sides:

Farm and Ranch Questionnaire - Page 5

AUTO INFORMATION

Driver Information

Click "Add another response" to insert additional drivers.

Driver Name:

Driver DOB:

Driver's License Number:

State:

Vehicle Information

Click "Add another response" to insert additional vehicles.

Year:

Make:

Model:

VIN:

Mileage:

WHEN FINISHED, CLICK "SUBMIT" TO SUBMIT YOUR COMPLETED FORM.

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