MUSIC Farm and Ranch Supplemental Application
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- Octavia Bryant
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1 Applicant s Name DBA Agent Name Address Physical Address Web Address Proposed Effective Date: From To (12:01 am Standard Time at the address of the Applicant) Years doing business under current name: years Applicant is: Type of farm or ranch Individual Joint Venture Years of Experience years Corporation LLC Partnership Estate The Farm is located Miles of (List Primary location first, other locations second, and land third. If more than four please attach separate sheet) No. of Acres Buildings Yes/No Section Township Range County State Zip Code Class 1-10 Coverage Requested Limits Cause of Loss Deductible A. Dwelling $ Basic Broad Special $ B. Private Structures 10 of A Basic Broad Special $ C. Household Personal Property 50 of A Basic Broad Special $ D. Loss of Use 20 of A $ E. Scheduled Farm Personal Property F. Unscheduled Farm Personal Property See Schedule Basic Broad Special $ See Schedule Basic Broad Special $ G. Other Farm Structures H. Bodily injury and property damage liability $ per occurrence $ General Aggregate MSA009 (01/14) Page 1 of 5
2 I. Personal Injury Limit $ per occurrence Building and Structures (Coverage A & G) Description Construction Age Condition Occupancy ACV Additional Interest Dwelling Dwelling Farm Shed Stable Scheduled Farm Personal Property (Coverage E) Description of Item Quantity or ID Number ACV Additional Interest Computer Feed and Seed Materials and Supplies Machinery and Equipment Animals over $2000 per head must be scheduled What are the principal products of the farm? Is the dwelling(s) occupied? If yes, by whom? Are there auxiliary heating devices in any buildings? Are there any bio-diesel operations on the premises? Are any structures not being used as originally intended? Are any structures not located on a year-round accessible road? Are there any mobile homes to be covered? Are their any lakes, ponds, swimming pools, or other recreational activities on the premises? Are the swimming pools properly fenced? Are there any commercial businesses conducted on the premises? Does applicant conduct any farm operations on premises such as seed or feed sales, X-mas tree lots, fruit or vegetable stands, etc? MSA009 (01/14) Page 2 of 5
3 Are customers allowed to pick their own fruit or vegetables? If yes, what kind? If yes, what type of equipment provided? (if any) Does the applicant operate a roadside stand on or off premises? Does applicant do any farm work or custom farming for others? Does applicant apply anhydrous ammonia to his farm or to others? Does applicant apply herbicide or pesticide for others? Has applicant ever had any complaints regarding pollution, overspray, waste run-off, or similar damages? Does applicant raise livestock of any kind? Does applicant have any involvement with horses? If yes, please specify Boarding for hire Horses for rent Training for hire Riding instruction Personal Ownership Showing/ Racing MSA009 (01/14) Page 3 of 5
4 Are the applicant s fences in good condition? Is there any custom feeding of livestock for others on premises? Does applicant own any watercraft or aircraft? Are the premises used for swimming or boating, hunting or fishing, hiking, trailrides, camping or picnicking, ATV tracks, or motorcycle courses? If yes please explain In the past 3 years has any company ever cancelled, non-renewed, declined or refused to issue similar insurance to you? Yes Yes No No Account Revenue Projections and History Year Payroll Gross Receipts Sub-Contracted Cost (Incl Cost of Materials) Next 12 Months Prior Carrier Information Year: Year: Year: Year: Year: Carrier Premium Deductible Premium Base Loss History Date of Loss Description of Loss Amount Paid Amount Reserved Claims Status (Open or Closed) Additional Insured Name of Individual Address What interests are to be covered? MSA009 (01/14) Page 4 of 5
5 Partnership Name of Partner(s) Address(es) Family Corporation Name of Members and owned Is Terrorism Coverage desired? (see attached disclosure) This questionnaire does not bind the Applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be part of the basis of the contract should a policy be issued. By signing you are hereby certifying that all information is accurate to the best of your knowledge. Applicants Signature Date Agents Signature Date MSA009 (01/14) Page 5 of 5
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