Questionnaire Selection Coverage List

Category: Personal Risks Risk: Farm Owner /Ranch Owner

GENERAL CLIENT INFORMATION

Account: ___________________________________________________________

Account Number: ____________________________________________________

Agency: ____________________________________________________________

Agency Number: _____________________________________________________

Producer: __________________________________________________________

Producer Number: ___________________________________________________

NAMED INSURED(S) __________________________________________________________________

MAILING ADDRESS___________________________________________________________________

Home: Telephone: _____________________

Email: _________________________
Fax: ___________________________
Work: Telephone: ______________________

Email: _________________________
Fax: __________________________
Cell phone numbers:

Named Insured - __________________
Spouse - ________________________
Others: _________________________
Marital Status: □ Married □ Single □ Divorced □ Separated □ Other ___________________________

Spouse/Significant Other: ___________________________

List below all people who currently reside in the household including:

Family members

Persons under 21 in the care of the insured (including foster children)

Other nonrelated residents (significant others, roomers, boarders, tenants, domestic employees)

List below all family members who currently do not reside in the household including noncustodial children, college students away at school, or any family living in an assisted living / skilled facility, etc.

Trust Name: __________________________________

Trustees: ____________________________________

Property: ____________________________________

Is the residence a historical landmark or showcase home? ___ Yes ___ No

If yes, are tours provided? _________ # of people________________
Is the property used for community activities? ___ Yes ___ No

If yes, describe the activities ________________________________________________
_______________________________________________________________________
Is the residence located in a flood plain? ___ Yes ___ No

If yes, does the insured carry flood insurance? ___ Yes ___ No
Is the residence located in a known earthquake area? ___ Yes ___ No

If yes, does the insured carry earthquake insurance? ___ Yes ___ No
Does the insured carry firearms or have firearms in the residence? ___ Yes ___ No

If yes, please complete the firearms supplement.
Have there been any water-related losses (including backup of sewers or drains)? ___Yes ___ No

If yes, what items remain in the home that were damaged and repaired instead of being replaced?
___________________________________________________________________________

___________________________________________________________________________

Is there any evidence of water leaking or seeping in the residence? ___Yes ___ No

Are there any odors in the house that could indicate the presence of mold? ___Yes ___ No

Are there underground or above ground storage tanks on premises? ___ Yes ___ No

Is there any storage of flammables, chemicals or fuels? ___ Yes ___ No

If yes, please describe ___________________________________________________________
_____________________________________________________________________________
Is there lead paint in the residence? ___ Yes ___ No

Is there chemical spraying on premises? ___ Yes ___ No

If yes, describe what is sprayed and whether the insured or contractor does the spraying.
_____________________________________________________________________________
Does the insured own, lease or rent additional residences? ___ Yes ___ No

If yes, build a separate questionnaire for each residence.
Does the insured own rental property? ___ Yes ___ No

If yes, build a questionnaire for rental property.
How long has the insured been a farmer? ____ years

How many family members are involved in the farming operations? ____

What percentage of household income is derived from farming operations? ___

How is the farming income derived? ___% Cattle ___% Poultry ___% Dairy

___ Other livestock – Describe _________________________________

___% Vegetable ___% Fruit ___% Grain

___% Other - Describe_________________________________

Number of acres owned or leased by the insured.:_____ acres

Number of acres: ____ leased ____owned

Number of acres the insured works under a crop share agreement: ____acres

Number of acres in active production: _____ acres

Number of acres in a government set aside program (CRP, WRP or similar plan).:___ acres

Number of acres worked by another farmer under a crop share agreement? ___ acres

Is the farm dwelling the insured's primary residence? ___ Yes ___ No

If no, answer the following questions.
Where is the insured's primary residence? ____________________________________

______________________________________________________________________

Who lives in the farm dwelling? _____________________________________________

_____________________________________________________________________

Does the insured carry multiple peril or crop hail coverage? ___ Yes ___ No

Are migrant or seasonal help used in crop production? ___ Yes ___ No

If yes, does the insured purchase workers compensation coverage? ___ Yes ___ No

Does the farmer have a contract to produce? ___ Yes ___ No

If yes, answer the following:

Who is the contract with? _________________________________________________

What is the term of the contract? ___________________________________________

What products are sold under the contract? __________________________________