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591843 (Rev 00 – 12/13) of 10

Agricultural Supplemental Application

*** THIS QUESTIONNAIRE MUST BE ATTACHED TO THE ACORD GENERAL APPLICANT INFORMATION APPLICATION – ACORD 125***

Applicant’s Name Agency

Number of years of farming/ ranching experience Is farming/ranching the primary source of income for this insured? Yes No

If no, describe primary income:

List any non-farming/non-ranching activities conducted by the insured.

Annual custom farming receipts (if applicable) (Custom farming is not the ongoing, year in…year out farming operations for others)

Does the insured conduct any Agritourism such as, but not limited to; petting zoos, dude ranches, public riding, etc.?

Yes No

If yes, details and receipts:

Are there any hunting or other sporting activities or competitions held on any premises? Yes No


Does the insured lease any area of land to others for hunting purposes? Yes No


Does the insured hold any part of the premises for lease or real estate development or speculation?

Yes No


Is there any oil, gas, mineral or water production on premises? Yes No


Does the Insured grow or store tobacco? Yes No

If yes, Number of Acres: % of Revenue:

Does the insured plan any construction or renovation work to be done on the premises in the next 12 months?

Yes No

If yes, explain:

Are there any unusual hazards on premises such as, but not limited to; open dumps, silage pits, sump holes, lakes, reservoirs, dams, pools, trampolines or airstrips?

Yes No

If yes, provide details:

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591843 (Rev 00 – 12/13) of 10

Does the insured own or operate any snowmobiles, four wheelers, dirt bikes or other ATV’s? Yes No

Number used for Farm __________ Pleasure __________ Used off premises? Yes No

Are there any horses on the premises? Yes No If yes, how many? _________________________

If yes, complete Acord 408 – Equine Liability Supplement.

Describe any use other than “pleasure use” such as showing, training, breeding, racing, rentals, trail rides, hay rides or rodeos:

Is there an arena exposure or any annual equine events? Yes No

Is any type of livestock on premises? Yes No

For poultry/swine accounts: Does the insured have an integrator*? Yes No

Name:

*An integrator is the contractual owner of the poultry/swine paying the insured to raise or maintain the livestock for production.

Are all livestock areas fenced? Yes No

Type: Condition:

Does the insured slaughter, butcher, process, package or otherwise prepare for “end consumer” his/her or anyone else’s livestock?

Yes No


Does the insured prepare, package and/or sell animal feed? Yes No


Does the insured mix, process, package or otherwise prepare for “end consumer” his/her or any other grower’s products?

Yes No


Does the insured process and/or conduct retail sales of milk products to the public? Yes No


Does the insured conduct any commercial food processing? Yes No


Does the insured maintain any fire and/or burglar alarms on the premises? Yes No

Do all dwellings and farm structures have lightning rods installed? Yes No

Are any dwellings on the premises unoccupied or occupied by someone other than the insured? Yes No

If yes, describe occupancy:

Does the insured maintain smoke detectors and/or fire extinguishers in dwellings occupied by tenants or employees?

Yes No

591843 (Rev 00 – 12/13) of 10

Liability Coverages Farm Type: Total Acres Owned Acres Leased/Rented Acres

Farm Liability and Operations: Per Occurrence General Aggregate Medical Payments

$5,000 per person Farm Chemicals Limited Liability

$25,000 $50,000 $100,000 Fire Legal Liability

$50,000 $100,000 $250,000 $500,000

Custom Farming: $ _________________________ annual receipts

Personal Liability: Named Insured(s):

Personal Liability – Additional Insured – Other Residents of the Household:

Named Insured(s) to be covered:

Farm Employers Liability and Medical Payments:

Liability Limit - Each Occurrence: Number of farm employees working:

180 days or more 41-179 days

Medical Payments Limit – Per Employee When farm employees work 40 or less days, number of man-days

Off Premises ATV Liability (include golf carts and low power vehicles):

Make Model Serial #

Off Premises Snowmobile Liability:

Make Model Serial #

Watercraft Liability:

Description Length Horsepower Rated Speed

(mph) Owner

(if not insured)

Location(s) (if necessary use separate schedule) Loc # 911 / Legal Address City

State ZIP Code County Number of Acres Protection Class

Loc # 911 / Legal Address City








591843 (Rev 00 – 12/13) of 10

Policy Level Property Options Deductible

$1,000 $2,500 $5,000 $____________________ Separate Wind of Hail Named Storm Wind / Hail

Inflation Guard % 4% 6% 8% ____________ %

Residential Property Deductible: if different than Policy Deductible $1,000 $2,500 $5,000 $______________________ Loc # Dwelling Limit HHPP Limit Adjacent Structures Limit Loss of Use Limit Year Built

Construction Type Area Rental (Y/N)

Seasonal (Y/N)

Valuation RC ACV

Type of Dwelling 1 2 3

Loc # Dwelling Limit HHPP Limit Adjacent Structures Limit Loss of Use Limit Year Built


Seasonal (Y/N)

Valuation RC ACV




Seasonal (Y/N)

Valuation RC ACV




Seasonal (Y/N)

Valuation RC ACV




Seasonal (Y/N)

Valuation RC ACV




Seasonal (Y/N)

Valuation RC ACV


Fire Protective Devices Theft Protective Device

Farm Buildings (if necessary use separate schedule) Loc # Building # Building Description Year Built Area (sq. ft.)

Construction Type Limit Valuation RC ACV FRC SA

Coins %

Type of Bldg 1 2 3

Distance to nearest building Enclosed Foundation Yes No

Condition E AA AV BA P

Loc # Building # Building Description Year Built Area (sq. ft.)


Coins %

Type of Bldg 1 2 3





Coins %

Type of Bldg 1 2 3





Coins %

Type of Bldg 1 2 3



591843 (Rev 00 – 12/13) of 10

Farm Buildings (continued) Loc # Building # Building Description Year Built Area (sq. ft.)


Coins %

Type of Bldg 1 2 3





Coins %

Type of Bldg 1 2 3





Coins %

Type of Bldg 1 2 3





Coins %

Type of Bldg 1 2 3



When SA, Stated Amount expiration date ________________ Poultry/Swine Buildings – Scheduled Only Truss Type: F – Frame M – Metal Additional Supports: KB – Knee Bracing CT – Collar Ties SP – Snow Poles OT – Other (describe)

Loc # Building # Building Property Type Roof Truss Type Additional Bracing Code(s) Year Built Length Width

Condition Distance to nearest other building Amount of Insurance Coverage/Coinsurance RC 100% ACV 90%









Earthquake

Location # Covered Property Amount of Insurance Deductible

591843 (Rev 00 – 12/13) of 10

Mine Subsidence

Location # Covered Property Amount of Insurance Deductible

Mobile Equipment (if necessary use separate inventory list)

Specifically Scheduled Items Blanket (Farm only)

Item # Year Description (Make & Model) Serial Number Amount of Insurance Valuation Coins %

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

ACV

Optional Property Coverages

Hay Coverage

Limit of Insurance

Loc. # Per Location Per Stack Per Building Deductible (Min. $1000) Coins %

Livestock Coverage

Covered Perils Type of Class of Livestock Per Animal Limit All Animals Limit Coins %

Basic Broad Including Earthquake Including Off-Premises Power Interruption

Basic Broad

591843 (Rev 00 – 12/13) of 10

Business Personal Property/Stock/Specifically Scheduled Property Loc # Building # Model Year Description

Serial # Amount of Insurance Valuation RC ACV FRC

Coins %

Loc # Building # Model Year Description


Coins %



Coins %



Coins %



Coins %



Coins %



Coins %



Coins %

Computer

Specifically Scheduled Items Blanket (Farm only)

Loc # Building # Item # Year Description (Make & Model)

Serial Number Amount of Insurance Valuation RC ACV

Coins %



Coins %



Coins %



Coins %



Coins %

591843 (Rev 00 – 12/13) of 10

Mortgagee / Loss Payees Loc # Building # Item # Name Interest

MG LLP LP CS Mailing Address City State ZIP Code

Loc # Building # Item # Name Interest MG LLP LP CS

Mailing Address City State ZIP Code







Additional Insured(s)

Name Relationship to Insured Property or GL? Insurable Interest

Property GL

Property GL

Property GL

Property GL

Property GL

Business Income

Loc. # Bldg. # Coverage Amount of Insurance

Income Monthly Limitation




Income Coverage Coinsurance %

Monthly Limitation % % % % %

Loss of Earnings from Eggs

Limit per layer: First laying cycle $ First Force Molt Cycle: $

Limit per occurrence: $ Deductible: % per occurrence

Mobile Equipment Rental Reimbursement - waiting period

No. of hours:

591843 (Rev 00 – 12/13) of 10

Property Additional Coverages

Standard Policy Limits Higher Limits Requested

Additional Debris Removal Expense $10,000

Emergency Removal Expense $10,000

Fire Department Service Charges $10,000

Inventory and Appraisals/Expense $5,000

Pollutant Clean Up and Removal $10,000

Recharge of Fire Extinguishing Equipment $10,000

Property Coverage Extensions


Fraud or Deceit $50,000

Newly Acquired Computers $50,000

Newly Acquired Mobile Equipment $100,000

Newly Acquired or Constructed Buildings $250,000

Personal Effects $10,000

Personal Property – Acquired Locations $250,000

Property Away from a Covered Location $100,000

Stock – Acquired Locations $250,000

Trees, Shrubs, Plants and Lawns $2,500

Property Coverage Extensions


Accounts Receivable $5,000

Brands or Labels Expense $5,000

Fine Arts, Furs, Guns, Jewelry, Metals $5,000

Fine Arts

Furs

Guns

Jewelry, watches, jewels, precious and semi precious stones

Silverware, goldware, pewterware or items plated with gold/silver

Money

Securities

Ordinance or Law: Increased Costs $10,000

Overseas Transit and Location $5,000

Property in Transit $10,000

Property on Exhibition $10,000

Sewer Backup and Water Below the Surface $1,000

Spoilage $5,000

Contamination Power Disruption

Tank Leakage $5,000

591843 (Rev 00 – 12/13) of 10

Utility Service Interruption $5,000

All Services Except: Overhead Transmission Power Lines Overhead Communication Transmission Lines Gas Water

Valuable Papers and Records – Cost of Research $5,000

Watercraft $5,000

Diagrams (show all structures and distance between, if a structure will not be covered on this policy indicate as ‘NC’) Location ______________________________________________________________________________________

NORTH

WEST

EAST

SOUTH

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