THIS DOCUMENT IS FOR REFERENCE PURPOSES ONLY PLEASE COMPLETE AGENT CENTER APPLICATION TO SUBMIT

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Derrick Bryan
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1 THIS DOCUMENT IS FOR REFERENCE PURPOSES ONLY PLEASE COMPLETE AGENT CENTER APPLICATION TO SUBMIT ** The Agent Center application requires further detail for any answers marked YES. ** AgriChoice Insurance Application Worksheet Property and Liability Applicant Profile Is the applicant known to the agent? Number of years Has the agent personally inspected the premises or property? Date of last inspection Has any policy been cancelled or non-renewed within the past five years? (t Applicable to Missouri) During the last five years, has any applicant been convicted of any degree of the crime of arson? Has the applicant been involved in any lawsuits? Have any judgments or liens been rendered against the applicant? Is the applicant a subsidiary of another? Does the applicant have subsidiaries? Operations Year Business Started Gross Annual Farming Receipts Is Farming the applicants main source of income? If, what is the main source of income? Who actually farms the premises? Identify the applicant s operations, including a description by premises: Bees Dairy Greenhouses Vineyards Fruits Fur Bearing Animals Nuts Livestock Mushrooms Nursery Stock Vegetables Other Sod Tobacco Flowers Worms Field Crops Poultry Farm Page 1 of 5

2 Does the applicant have a website pertaining to these operations? Website address Are any of the applicants operations insured with another company? Does the applicant own or operate any other type of business? Does the applicant perform maintenance on equipment? Is a formal safety program in existence? Named Insured Entity Type: SS# (if entity type is Individual or Partnership): Mailing Address: Account Contacts Named Insured Contact (Name, Home Address, Home Phone, Work Phone, Fax): Drivers Does the account present any driving exposures? (e.g., scheduled autos, auto service/repair, recreational vehicles? Does the applicant obtain MVR verifications? Does the applicant have a specific driver recruiting method? Explain Are any drivers not covered by Workers Compensation? Explain Are there any drivers with moving traffic violations? Explain Prior Carrier Has the applicant had prior insurance? Prior Carrier Effective Date Expiration Date Lines of Business Loss History Has the applicant had any losses within the past five years? Occurrence Date Line of Business Amount Paid Farm Page 2 of 5

3 Farm Common Information Premises Information Does the applicant own a dog? Number and Breed Any history of dog bites or destruction of property? Does the applicant have any potentially dangerous or exotic animals? Is there a swimming pool on premises? (If yes, complete questionnaire) Above Ground In Ground Is there a trampoline on premises? (If yes, complete questionnaire) Is there an airstrip on premises? Are there any unusual hazards such as (but not limited) open dump pits, silage pits, sump holes, ponds, lakes or reservoirs? Are the farm premises open to the public for activities such as roadside stands, u-pick recreational, rent-a-garden, auction, sales, show, food or beverage service, hay rides, fishing, kennels, animal breeding or Christmas tree sales uses? Is any part of the farm used or leased for organized recreational use? Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other than farming? Are any premises used for hunting purpose? Does the applicant allow others to hunt on premises? Is there a fee charged for these activities? Are any items provided? If yes, to any, please explain Operations Does the applicant milk cows? If yes, number of cows milked? Is there any processing of milk? Is there any retail sales of milk products to the public? Does applicant mix, process, slaughter, butcher or otherwise prepare for any end consumer his or any other grower s products? Are independent contractors hired to perform any farming operations? Does applicant handle product, such as seed, fertilizer, sprays, etc. for resale? Farm Page 3 of 5

4 Does applicant build, repair or design machinery, equipment or systems for anyone at a charge of fee? Are any contract or service operations performed for others such as snow removal, filing, excavating or ditching? Does the applicant maintain a non-farming office or private school in an insured building? Livestock If any livestock are kept, are all areas adequately fenced and are fences in a good state of repair? Open range area Closed range area Does the applicant own any horses? If yes, how many? Any non-owned horses on any applicant premises? Does the applicant board, race, breed or rent horses? Pollution Does the applicant apply anhydrous ammonia to his farm? Does the applicant apply anhydrous ammonia to the farms of others? (Proof of coverage required) Receipts $ Are pesticides stored in a locked enclosure? Does the applicant apply herbicides or pesticides for others? Has the applicant ever had any complaints regarding pollution, waste run-off or similar damages? Miscellaneous Does the applicant own a boat? (may need boat application) Does the applicant maintain any vacation or seasonal premises? Are any hold harmless or indemnifying agreements in effect? Does the applicant serve on any boards for remuneration? Is any land for real estate development or speculation? Farm Page 4 of 5

5 Property Are all residences and buildings located on a year-round accessible road? If no, explain Is plastic-based insulation used in any farm buildings? In which buildings? Are all buildings used as originally intended? If no, explain How far away from structures is gasoline or fuel stored? Is any property kept on a location(s) other than an insured location? Where? During farming season During off-season Maximum value of equipment at any one location. What is the radius of operations of equipment? (miles) Is there a year-round water supply usable for fire protection? Source Hydrant within 1,000 ft Pond/Lake Well Other Total water capacity Is the entire premises occupied year-round? (premises diagram required) If yes, premises diagram required. If no, explain Are poultry or swine brooders used at this building? Have the heating, plumbing, roofing and/or wiring system been updated since the original construction? Select updated items Year of last update Heating Plumbing Roofing Wiring Should any Additional Insureds be listed for coverage under this policy? If yes, provide name, address and interest applies to Are there mortgagees, loss payees, or other parties with interest in any property? If yes, provide interest type, name and address Is coverage bound? Agent tes / Comments Farm Page 5 of 5

FARM LIABILITY APPLICATION APPLICANT INFORMATION SECTION

FARM LIABILITY APPLICATION APPLICANT INFORMATION SECTION FARM LIABILITY APPLICATION Renewal of # APPLICANT INFORMATION SECTION Date: Producer: : Underwriter: Producer Contact: Producer Phone # Producer FAX # Producer Code Producer Email: Farm or General Liability