DeMasters-Daniel Homeowners Quote

Request for Farm Liability Quote

NOTE: Please provide all pertinent information. After filling in the information, click the submit button at the bottom of the form to send the information to us. You will receive a confirmation page, indicating that the form was sent correctly.

Personal Data

Name:
Mailing Address:
Legal Location:

Rating Data

Primary Farm Acerage:
Total Farm Acerage:
Primary Farm Location:

Additional Farm Premises and Farms Rented to Others:

Legal Location	Acerage	Additional Structures Describe (OB, dwell, etc)

Have Additional Farm Premises and Farms Rented to Others been Inspected? Yes No
Are Premises and Fences of Farm and Farms Rented to Others Well Maintained? Yes No
Is Animal Collision Desired? Yes No Number of Head:
Custom Farming Receipts (Excess over $2,000):
Incidental Farm Employee Coverage: Employees Working 40 - 180 Days: # of Employees Employees Working 1- 40 Days: # of Days Worked
Additional Insured: Name & Address: Relationship: Interest:
Corporation or Partnership? Yes No Name of Corporation or Partnership: Relationship Between the Insureds:
Insured's Occupation: Spouse's Occupation:
Number of claims filed last 3 years: Cause of claims:

Other and Contact Data

Additional information you would like us to consider (optional):

Telephone Number:
Fax Number:
E-Mail:
Send response by: Phone Fax E-mail

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