FARM COMBINED QUOTE REQUEST FORM

Transcription

1 FARM COMBINED QUOTE REQUEST FORM Renewal Date DD/MM/YYYY Deadline DD/MM/YYYY Present Insurer Target Premium Broker/Contact/ /Fax Full Name of Proposer, including forenames Premises 1 Premises 2 Postcode Postcode Type of Farm Arable Dairy Beef Sheep Pigs Poultry Ag. Cont. Non-Farming Activities HOUSEHOLD BUILDINGS Premises 1 Standard Super *Occupancy: I/F L UN HL Premises 2 Standard Super *Occupancy: I/F L UN HL Premises 3 Standard Super *Occupancy: I/F L UN HL Construction: Brick, Stone, Slate and / or Tile Other: *Occupancy: I/F - Insured/Family L Let,no DSS or Students UN Unoccupied HL - Holiday Let HOUSEHOLD CONTENTS Premises 1 Standard Super Specified Items: Premises 2 Standard Super Specified Items: Premises 3 Standard Super Specified Items: Freezer Contents *High Risk Property 25% of sum insured or 3,000 any one item Construction: Brick, Stone, Slate and / or Tile Other: HOUSEHOLD ALL RISKS Premises 1 Unspecified Specified Money/ Credit Cards Specified Premises 1 Unspecified Specified Money/ Credit Cards Specified Page 1 of 5

2 DOMESTIC ANIMALS *Dog/ Cat/ Horse Class A/ Horse Class B - *Male/ Female *delete as appropriate DOB: Breed: Name: Colour: Sum Insured Is the animal healthy? Yes No Vets Fees Recovery Costs CARAVANS Make: Model: Age: Sum Insured: FARM BUILDINGS Optional Covers: Fire, lightning, aircraft, explosion, earthquake, subterranean fire Storm, tempest, flood Falling trees Burst pipes, tanks Riot, malicious damage Impact Premises 1 Unheated Farm Buildings Premises 1 Heated Farm Buildings Other Details Built: Brick, Stone, or Concrete Other Roofed: Slate, Tile, Metal or Asbestos Other FARM CONTENTS damage, impact, falling trees Hay & Straw Storm/ flood Grain Storm/ flood Roots & Silage Storm/ flood Growing Crops Produce, as a single item Storm/ flood Deadstock Storm/ flood Machinery, excluding tools/ ATV s Storm/ flood Hand Tools Storm/ flood ATVs/ Quad Bikes Storm/ flood Dairy Equipment Storm/ flood Grain Drying Equipment Storm/ flood Heated Poultry Equipment Storm/ flood Overground Services (FL) Fences,Gates,Hedges & Walls (FL) Page 2 of 5

3 LIVESTOCK Optional Covers:- damage, impact, accidental electrocution of livestock, falling trees Mysterious Disappearance Fatal Injury to Livestock (straying away from premises) and Transit Worrying Fatal Injury to Livestock (whilst on own premises) Cattle Sheep Pigs Horses Poultry Heated/Unheated Sheep dogs (under 500 per dog) Sheep dogs (over 500 per dog) Foot & Mouth Brucellosis Positive Milk Tests Yes No No. of Abortions All Risks Mortality:-Type of Animal Age Sum Insured Name & ID Loss of Use Loss of Use All Risks Mortality:-Type of Animal Age Sum Insured Name & ID Loss of Use Loss of Use LOSS OF REVENUE Optional Cover: damage, impact, falling trees, electrocution of livestock Storm, tempest, flood Cereal/ Arable Pigs Dairy Poultry Beef Eggs Sheep Hire Extn. Other Details EMPLOYERS LIABILITY Farming AWB cover Clerical/ Domestic Ag. Contracting Forestry Other Details Are you exempt from having an Employer Reference Number (ERN) Yes No? If No please advise the ERN PUBLIC LIABILITY Total Acreage Farming t/o Poultry/ Pig t/o Rental Income Ag. Contracting t/o Crop Spraying t/o No. of Shoots Shoot t/o No. of Guns Holiday accommodation t/o Caravan/campsite pitches Any ancillary facilities provided? Other Occupation t/o Details Page 3 of 5

4 BUSINESS MONEY Annual Carryings Cash in Safe Overnight Transit Limit/any other loss PA/ Assault Extension MILK IN TANKS Loss of Milk Sum insured Bulk Milk Tank Description Antibiotics Contamination Cover OWN GOODS IN TRANSIT Limit any one load Number of Vehicles DETERIORATION OF STOCK Make & Model of Freezer Year of Make Type of Stock Sum Insured If not confirm annual test by qualified engineer FARM ALL RISKS Territorial Limit General Office Contents Premises GB Radio equipment/ Mobile Phones Premises GB Semen Flask/ Contents Premises GB Oil/ Fertiliser Tanks & Contents Premises GB Cattle Passports Premises GB Other Details COMPUTERS Make Model Sum Insured Serial No. YOM Territorial Limits HAIL Maize, wheat, barley, oats, rye, triticale, sugar beet, potatoes, grass, fodder crops Linseed, osr, peas (vining/ harvesting), beans (harvesting), grass (seed only) Acreage Acreage PERSONAL ACCIDENT & SICKNESS Name Occupation DOB Capitals TTD/ TPD Sickness Benefits Death & Capitals 10,000 1 unit TTD/ TPD 50/ 20 1 unit Sickness 50 1 unit Page 4 of 5

5 LEGAL EXPENSES Wages Acreage GENERAL QUESTIONS Please tick the box if no losses in the past 3 years If losses have occurred please give full details below:- Any other relevant information please advise below:- eg - H&S Prosecutions AIUA Grimbald Crag Close, Knaresborough, HG5 8PJ T: F: reception@aiua.co.uk AIUA is a trading name of Geo Underwriting Services Limited Registered Address: Towergate House, Eclipse Park, Sittingbourne Road, Maidstone, Kent ME14 3EN Registered in England No Authorised and regulated by the Financial Conduct Authority. FCA Register Number Page 5 of 5