5 Park Plaza Knights Way Battlefield Shrewsbury SY1 3AF Tel: 01743 460555 e-mail: info@farmsure.co.uk Broker Details Farm Combined Quote Request / Proposal Form Please complete this form clearly using BLOCK CAPITALS Brokerage name : Telephone : Contact Name : e-mail : Date Submitted : Date quote required by : *IMPORTANT* Should our quotation be accepted, the policy will be issued on a Statement of Fact basis. Documents will be issued in accordance with the information provided on this form and any Supplementary Questionnaire required. Proposer Details Company Name or Trading Name of Principal or Partnership Full Name of Principal or each Partner or Director Address of Main Farm Post Code Addresses of other farms /locations Farming Activities (e.g. Arable, Dairy,Beef,Pigs,Poultry etc.) Non - Farming Activities (e.g. Property Owners, Shop, Fishing, Caravans, Agricultural Contracting etc.) Renewal Date Current Insurer & Policy Number Target Premium incl IPT Page 1 of 9
General Information 1) Have you or any director or partner (in this or any other trading name): a) suffered any loss or damage or had any claims made against you (whether insured or not) in the last 5 years? Yes No If Yes, please give details: NB. If the quote is accepted written confirmation of the claims history from the previous insurer(s) will be required Date Circumstances Amount Paid or O/S b) been declared bankrupt, convicted of any criminal offence, had any policy cancelled, declined or terms imposed or prosecuted under heath and safety legislation? Yes No If YES provide full details : 2) Is the Farm tenanted? Yes No 3) Do you have a written Health and Safety policy? Yes No 4) Do you have an Asbestos Management Program? Yes No 5) Are all the Buildings in a good state of repair? Yes No If No please provide full details 6) Is there a mortgage /bank interest? Yes No If Yes please provide full details 7) Do you require a 3 year Long Term Agreement? (5% discount) Yes No 8) Do you require the Additional Excesses & Limits shown below in return for a premium discount? Yes No Property Damage section - 250 excess all claims - Haystacks- inner limit of 25,000 per location Livestock (Non-Disease) section - 250 excess all claims Liability section Public/Products Liability - 100 excess for Third Party Property Damage Personal Accident section - 7 day deferment period for temporary disablement Home section - 100 excess all claims (other than subsidence 1,000 excess) Page 2 of 9
Farm Property Damage Standard Cover: Fire, Lightning, Aircraft, Explosion, Earthquake, Escape of Oil, Falling Trees, Riot & Malicious Damage, Impact & Defective Oil Vaporisation (all with 100excess) Farm Buildings Sum Insured Additional Covers Required Yes No Heated Buildings Unheated Buildings Basis of Claims Settlement : select the one required - Rebuild in modern materials Yes No - Rebuild in original/traditional materials Yes No NB. the sum insured must be set accordingly Storm & Tempest (250 xs per premises) Theft (100 xs) Burst Pipes & Loss of Metered Water (100xs) Implosion of Grain Towers (100 xs) Are any Buildings Listed or of Non-standard construction? Yes No Please provide separately full details of any building tenanted for farming or other commercial use, listed buildings or buildings of non-standard construction. For Heated Buildings, please provide Full Details as to construction, age and type of heating used. Machinery, Tools & Plant This excludes farm bikes, quad bikes, all-terrain vehicles, tractors and other motorised vehicles unless Motorised Vehicles selected below Sum Insured Additional Covers Required Yes No Milking Equipment & other fixed equipment Grain Dryers Motorised Vehicles All other Machinery & Plant Theft (100 xs) AD to Fixed Equipment (100 xs) Transit (100 xs) Produce & Deadstock Sum Insured Additional Covers Required Yes No Produce & Deadstock Grain in Store Other (Please give details below) Theft (100 xs) Storm & Tempest (Grain in Store only) (250xs) Transit (100 xs) Other Details: (e.g. Growing Timber) Other (Cover as described below) Sum Insured Covers Provided Yes No Boundary Walls, Hedges, Fences & Gates F, L, Expl, Eq, Riot & MD, Impact (100 xs) Office Contents All Risks (100 xs) Computers & Ancillary Equipment All Risks (100 xs) Semen in Flasks All Risks (100 xs) Cattle Passports All Risks (100 xs) Other (please give details) Page 3 of 9
Livestock (Non-Disease) Standard Cover: Fire, Lightning, Aircraft, Explosion, Earthquake, Electrocution, Riot & Malicious Damage (All 100 xs) Livestock Sum Insured Additional Covers Yes No Cattle Sheep Pigs in Heated Buildings Pigs - other Poultry in Heated Buildings Poultry other Straying (100 xs) Transit (100 xs) Sheep Worrying (100 xs) Cattle Worrying (100 xs) Theft/Mysterious (100xs) Disappearance Horses Other (Please give details below) TOTAL SUM INSURED Livestock (Disease) Diseases Foot & Mouth (6 months loss of income) per month Brucellosis (full Herd Value) T.B. (full Herd Value) Other please specify Details: Specified Animals (Death by accident, injury, illness, disease, gassing, poisoning, theft, or unexplained disappearance) Name & Breed Age Use Infertilty Y/N Sum Insured Note : A Supplementary Questionnaire will be required for each animal before cover can be granted. Vets Certificate required for Animals with a sum insured of 2,500 or over before cover granted. Page 4 of 9
Liability EMPLOYERS LIABILITY - 10,000,000 Limit of Indemnity AWB Cover included Annual Wages Farm/Estate/Casual Workers ex. Forestry Tree-felling & Use of Woodworking Machinery Clerical Other (Please Specify) PAYE Employer Reference Number (ERN) or if exempt state Exempt PUBLIC/PRODUCTS LIABILITY - 5,000,000 Limit of Indemnity Note: A Supplementary Pollution Questionnaire may be required. Acreage Farmed Woodland/Rough Grazing/Moorland/Land Let Acres : Acres : Do you require the Pollution & Contamination Statutory Enforcement Costs Extension? Yes No Agricultural Contracting Nature of Work Undertaken Turnover per annum % of Total Farming Turnover Shoots/Clay Pigeon Shoots including Member to Member Liability Number of Days Per Year? Maximum No. of Guns on any one day? Shoots ( Max 20 people) Clay Pigeon Fishing River Yes No Number of Rods Lake/Reservoir Yes No Number of Rods Holiday Lets/ Camping Facilities Type of Let Number Flats/Cottages Caravan /Camping Pitches Permanent Caravans Other activities please specify e.g. Farm shops,walks, school visits, open days etc Page 5 of 9
Loss of Revenue Non-Livestock Revenue Standard Cover (as per Property Damage Section) Non-Livestock Farming Activity Annual Revenue Additional Covers Required Yes No Loss of Rent (Commercial/Holiday Lets etc) Riot & Malicious Damage Theft Transit Storm Damage to Buildings Livestock Revenue Standard Cover (as per Livestock (Non-Disease) Section) Livestock Farming Activity Annual Revenue Additional Covers Required Yes No Riot & Malicious Damage Theft Transit Straying Worrying Alternative basis if Revenue cover not required Additional Expenditure (Additional Cost of Working) Tick if Required Sum Insured Milk in Tanks Tick the sum insured required 3,000 any one claim 6,000 any one claim 9,000 any one claim Is the Accidental Milk Contamination Extension required? Yes No Business Money Estimated Annual Cash Carryings Max amount in Transit or on Premises during working hours Max amount in Safe Please give Details of Safe Commercial Legal Expenses Yes No Total Annual Wages Limits : 100,000 any one event ; 1,000,000 all claims and legal proceedings in any Period of insurance Page 6 of 9
Personal Accident 1 unit = 5,000 Death & Capital Sums 50 per week Temporary Total Disablement 20 per week Temporary Partial Disablement A NIL Deferment Period applies as standard A discount is available if a 7-Day Deferment Period is selected Insured Persons Name Date of Birth Occupation No. of Units Tick if 7-Day Deferment required Please give details of any Pre-existing conditions or non farming activities undertaken Name Medical conditions/activities Commercial Deterioration of Stock (spoilage of chilled or frozen farm produce - 50 excess) Location of Equipment Make & Description of Equipment Year of Make Description of Stock Sum Insured (max 4,000) Page 7 of 9
Home Insurance (please copy if more than one address to be insured) NB. If a number of tenanted residential properties are to be included please provide full details separately Address Postcode Construction Year Built No. Bedrooms Alarmed? Yes No Home Buildings Sum Insured Cover Required Standard Standard + Accidental Damage Excess Standard (50) 150 250 Home Contents Sum Insured Cover Required Standard Standard + Accidental Damage Excess Standard (50) 150 250 High Risks Items 5000 (Basic) Other Single Article 1000 (Basic) Other Unspecified All Risks 2,000 1,500 Single Article Limit Personal Legal Expenses included if Contents selected 4,000 2,000 Single Article Limit 2,000 Single Article Limit Specified All Risks Items (valuations required for items over 2500 before cover granted) Description Sum Insured 1 2 3 4 5 6 Caravans Make Model Age Static or Touring? Sum Insured Page 8 of 9
ADDITIONAL INFORMATION please insert any further information which may influence the assessment and acceptance of this insurance IMPORTANT Should you wish to accept the quotation given this form will be considered as the proposal document and the policy will be issued with a Statement of Fact based on the information provided. Therefore please read the following carefully before you sign and date the Declaration. You must make a fair presentation of the risk. A fair presentation of the risk is one in which every material representation as to a matter of fact is substantially correct and every material representation as to a matter of expectation or belief is made in good faith, and are those facts which the underwriter may wish to know in deciding whether to underwrite the risk and/or the terms upon which to underwrite the risk. The requirement to make a fair presentation of the risk exists throughout the life of the policy. This may be relevant to your activities or to your personal or financial background. Failure to make a fair presentation of the risk could result in your policy being invalidated. Should you be in doubt as to whether information is accurate or material, then you must disclose it to us. We recommend that you should keep a record, including copies of letters and this quote request form, of all information supplied to us for the purpose of entering into this insurance. DECLARATION Before signing the Declaration please check your answers carefully particularly if this Form is not completed in your own hand. I/We declare that to the best of my/our knowledge and belief the answers given are true and complete I/We agree that if any answers have been completed by any other person, such person shall for that purpose be regarded as my/our agent and acting on my/our behalf, and not the agent of Farmsure Underwriters Ltd I/We declare that this Quote Request Form is for insurance in the normal terms and conditions of Farmsure Underwriters Ltd s policy I/We agree that the information provided on this Quote Request Form and any information supplied by me/us shall be incorporated in and form part of the insurance contract. I/We understand that no cover shall be in force until the proposal has been accepted by Farmsure Underwriters Ltd or its agents and that Farmsure Underwriters Ltd reserves the right to reject the proposal, to apply special terms and/or investigate claims. Signed Date of signing Signing this Quote Request Form does not bind the Applicant or the Insurer to complete the insurance. The completed form should be returned to your Broker/Intermediary. Company Registered in England No. 4527193 at 5 Park Plaza, Knights Way, Battlefield, Shrewsbury SY1 3AF Authorised and regulated by the Financial Conduct Authority Page 9 of 9