Small Farm Insurance Application

Applicant Information

Are you a member of a Specific Farmers Market?

/>Yes

/>No

Please list the Specific Farmers Market(s):

Named Insured:
(if a partnership, please provide all individuals' names)

Business Name:

Phone Number:
Please enter in XXX-XXX-XXXX format.

Email Address:

Website Address:

Mailing Address:

Street Address:

City:

State:

Zip Code:

Is the Property Address for the Business Location different than the mailing address?:

/>Yes

/>No

(if different from mailing address)

Street Address:

City:

State:

Zip Code:

Farm Details

How many years has Named Insured been in business?:

What type of business is the Named Insured?:

/>Individual

/>Partnership / Joint Venture

/>Corporation / Organization / Any Other

Do you rent or own the property you farm?:

/>Rent

/>Own

How many Acres is the property you farm?:

Please provide a detailed description of this business including products and services you sell under this entity:
Please limit description to 500 characters or less.

Limits / Coverage Requested

Desired Effective Date:
MM/DD/YYYY format

General Liability

Business Liability each occurrence:
(Medical Payments of $5,000 each person included).
Class limitations and exclusions may apply.

/>$300,000

/>$1,000,000

Deductible

Standard Deductible is $250
(No other deductible available)

Additional Insured Information

Do you need an Additional Insured?:

/>Yes

/>No

Name:

(if applicable)

Street Address:

City:

State:

Zip Code:

What interest does the additional insured have in the insured's business?
(Response is mandatory. Please limit response to 500 characters or less.):

General Underwriting Information '.$underwrite['question'].'

Yes

'; output_error('underwrite_'.$i, $error_msg); echo ' '; if( ! empty($underwrite['additional'])) { $j = 1; foreach($underwrite['additional'] as $detail) { echo '

'.$detail.' '; output_error('detail_'.$i.'_'.$j, $error_msg); echo '

'; $j++; } } $i++; } ?>

Optional

Do you belong to a trade association related to your Home Business? If so, what is the name of the trade association(s)?

Do you regularly visit a website related to your Home Business? If so, what is the website address(es) (URL)?

Do you receive a printed publication related to your Home Business? If so, what is the name of the printer publication(s)?

Applicant's Statement

IMPORTANT: The statements (answers) given above are true and accurate. The applicant has not willfully concealed or misrepresentedany material fact or circumstance concerning this application. This application does not constitute a binder.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerningany material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties. (Not applicable in LA, MD, NM, OK, PA, TN, VA, and WA.)

Maryland (MD): Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly andwillfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Louisiana (LA), New Mexico (NM): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents falseinformation in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison (NM: civil fines andcriminal penalties).

Oklahoma (OK): Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurancepolicy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania (PA): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance orstatement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any factmaterial thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee (TN), Virginia (VA), Washington (WA): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

By checking the box to the left and submitting this form, I agree to the above Applicant's Statement and agree that all information entered was done so accurately and truthfully.