Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 401 (2013/09)
Agriculture Application
Applicant Information Section
ACORD 401, Agriculture Application Applicant Information Section, is
used in the underwriting process for any Agriculture account. The Applicant Information
Section is the foundation on which the ACORD Agriculture application program is built.
This form contains information that is not duplicated on other ACORD agricultural
application forms. The Applicant Information Section is a required part of every
Agriculture submission, and no such application is complete without it.
IDENTIFICATION SECTION Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION FAX
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Company Policy or Program Name
Enter text: The description of an independently filed policy or program that may be
optionally available from the insurance company. It may also be used to name the
subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Program Code
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION Account No.
Enter identifier: The account number to be used for billing purposes. This is the billing
number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the
insurer assigns. If the account already exists, the agent should provide the previously
assigned number.
IDENTIFICATION SECTION New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION Renwl
Check the box (if applicable): Indicates the response expected from the company is a
renewed policy.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Direct Bill
Check the box (if applicable): Indicates if the policy is to be direct billed.
IDENTIFICATION SECTION Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
IDENTIFICATION SECTION Payment Plan
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -
Quarterly, etc.).
IDENTIFICATION SECTION Quote
Check the box (if applicable): Indicates the response expected from the company is a
quote.
IDENTIFICATION SECTION Bound (Checkbox)
Check the box (if applicable): Indicates the coverage has been bound. As used here, if the
risk is bound, list the date and time coverage began and attach a copy of the binder.
IDENTIFICATION SECTION Bound Date
Enter date: The date the policy status becomes effective. This date is used for policy
statuses of bound, change, and cancel.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Issue Policy (Checkbox)
Check the box (if applicable): Indicates the response expected from the company is an
issued policy.
IDENTIFICATION SECTION Policy Type
Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Est Total Premium
Enter amount: The estimated total cost amount of the policy.
IDENTIFICATION SECTION Deposit
Enter amount: The amount of the premium received as a deposit.
IDENTIFICATION SECTION Balance
Enter amount: The amount still owed on the policy.
IDENTIFICATION SECTION Agriculture Property
Check the box (if applicable): Indicates the Agriculture Property section is attached to this
policy.
IDENTIFICATION SECTION Personal Property
Agriculture Property Section
Scheduled and Unscheduled
Check the box (if applicable): Indicates the Agriculture Property Schedule and
Unscheduled Personal Property section is attached to this policy.
IDENTIFICATION SECTION Agriculture Liability
Check the box (if applicable): Indicates the Agriculture Liability section is attached to this
policy.
IDENTIFICATION SECTION Diagram
Agriculture Premises / Location
Check the box (if applicable): Indicates the Agriculture Premises Location Diagram section
is attached to this policy.
IDENTIFICATION SECTION Property Inventory Form
Agriculture Property Section
Unscheduled Farm Personal
Check the box (if applicable): Indicates the Agriculture Property Unscheduled Farm
Personal Property section is attached to this policy.
IDENTIFICATION SECTION Livestock Mortality Section
Check the box (if applicable): Indicates the Livestock Mortality section is attached to this
policy.
IDENTIFICATION SECTION Equine Liability Section
Check the box (if applicable): Indicates the Equine Liability section is attached to this
policy.
IDENTIFICATION SECTION Commercial Auto
Check the box (if applicable): Indicates the Business Auto section is attached to this
application.
IDENTIFICATION SECTION Commercial General Liability
Check the box (if applicable): Indicates the Commercial General Liability section is
attached to this application.
IDENTIFICATION SECTION Homeowners
Check the box (if applicable): Indicates the ACORD 80, Homeowner Application or
ACORD 89, Residential Section is attached to this policy. The ACORD 89 must be used
in conjunction with ACORD 88, Personal insurance Application, Information Section.
IDENTIFICATION SECTION Personal Auto
Check the box (if applicable): Indicates the Personal Automobile (ACORD 90) section is
attached to this policy.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Personal Inland Marine
Check the box (if applicable): Indicates the Personal Inland Marine (ACORD 81) section is
attached to this policy.
IDENTIFICATION SECTION Umbrella
Check the box (if applicable): Indicates the Umbrella section is attached to this application.
IDENTIFICATION SECTION Watercraft
Check the box (if applicable): Indicates the Watercraft (ACORD 82) section is attached to
this policy.
IDENTIFICATION SECTION Other One
Check the box (if applicable): Indicates that a section that is not listed specifically on the
form is attached to this application.
IDENTIFICATION SECTION Other Description One
Enter text: The type of section being attached to this application.
APPLICANT INFORMATION Other Named Insureds)
Name (First Named Insured &
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION First Named Insured)
Mailing Address Incl ZIP+4 (of
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION First Named Insured):
FEIN or Social Security Number (of
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Phone (A/C, No, Ext):
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Experience by the Insured
Number of Years Farming
Enter number: The number of years the insured has had experience in farming.
APPLICANT INFORMATION E-Mail Address(es)
Enter text: The named insured's primary e-mail address.
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Section Name
Field Name
Field and/or Section Description
APPLICANT INFORMATION Website Address(es)
Enter text: The primary website address for the named insured.
APPLICANT INFORMATION Individual
Check the box (if applicable): Indicates the legal entity code for the named insured is
Individual.
APPLICANT INFORMATION Partnership
Check the box (if applicable): Indicates the legal entity code for the named insured is
Partnership.
APPLICANT INFORMATION Corporation
Check the box (if applicable): Indicates the legal entity code for the named insured is
Corporation.
APPLICANT INFORMATION Joint Venture
Check the box (if applicable): Indicates the legal entity code for the named insured is
Joint Venture.
APPLICANT INFORMATION Subchapter S Corporation
Check the box (if applicable): Indicates the legal entity code for the named insured is
Subchapter S Corporation.
APPLICANT INFORMATION Not For Profit Org
Check the box (if applicable): Indicates the legal entity code for the named insured is Not
For Profit Organization.
APPLICANT INFORMATION LLC
Check the box (if applicable): Indicates the legal entity code for the named insured is
Limited Liability Corporation.
APPLICANT INFORMATION No. of Members and Managers
Enter number: The number of members and managers for a limited liability corporation.
APPLICANT INFORMATION CR Bureau Name
Enter text: The code identifies an external source that may be used to provide financial or
credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax,
Trans-Union, etc.
APPLICANT INFORMATION ID Number
Enter identifier: The identifier assigned by the credit bureau for the risk.
APPLICANT INFORMATION Inspection Contact
Enter text: The name of the person to contact to arrange for a premises inspection. This
should be an individual under the insured's employment, not the insurance agent's name
and number.
APPLICANT INFORMATION Phone (A/C, No, Ext)
Enter number: The telephone number of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment.
APPLICANT INFORMATION E-Mail Address
Enter text: The e-mail address (if applicable) of the person to contact to arrange for a
premises inspection. This should be an individual under the insured's employment, not
the insurance agent's name and number.
APPLICANT INFORMATION Accounting Records Contact
Enter text: The name of the person to contact for accounting information. This should be
an individual under the insured's employment, not the insurance agent.
APPLICANT INFORMATION Phone (A/C, No, Ext)
Enter number: The telephone number of the person to contact for accounting information.
This should be an individual under the insured's employment, not the insurance agent's
name and number.
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Section Name
Field Name
Field and/or Section Description
APPLICANT INFORMATION E-Mail Address
Enter text: The e-mail address (if applicable) of the person to contact for accounting
information. This should be an individual under the insured's employment, not the
insurance agent's name and number.
TYPE OF FARM / RANCH
Aquaculture
Check the box (if applicable): Indicates the nature of the operation is an aquaculture farm /
ranch.
TYPE OF FARM / RANCH
Cotton
Check the box (if applicable): Indicates the nature of the operation is a cotton farm / ranch.
TYPE OF FARM / RANCH
Dairy
Check the box (if applicable): Indicates the nature of the operation is a dairy farm / ranch.
TYPE OF FARM / RANCH
Field Crops
Check the box (if applicable): Indicates the nature of the operation is a field crops farm /
ranch.
TYPE OF FARM / RANCH
Flowers
Check the box (if applicable): Indicates the nature of the operation is a flowers farm /
ranch.
TYPE OF FARM / RANCH
Fruit/Citrus
Check the box (if applicable): Indicates the nature of the operation is a fruit / citrus farm /
ranch.
TYPE OF FARM / RANCH
Fur Bearing Animals
Check the box (if applicable): Indicates the nature of the operation is a fur bearing animals
farm / ranch.
TYPE OF FARM / RANCH
Greenhouses
Check the box (if applicable): Indicates the nature of the operation is a greenhouse farm /
ranch.
TYPE OF FARM / RANCH
Hobby/Gentleman Farm
Check the box (if applicable): Indicates the nature of the operation is a hobby /
gentleman's farm.
TYPE OF FARM / RANCH
Horses
Check the box (if applicable): Indicates the nature of the operation is a horse farm / ranch.
TYPE OF FARM / RANCH
Livestock Confinement
Check the box (if applicable): Indicates the nature of the operation is a livestock
confinement farm / ranch.
TYPE OF FARM / RANCH
Livestock Feedlot
Check the box (if applicable): Indicates the nature of the operation is a livestock feedlot
farm / ranch.
TYPE OF FARM / RANCH
Livestock Grazing
Check the box (if applicable): Indicates the nature of the operation is a livestock grazing
farm / ranch.
TYPE OF FARM / RANCH
Livestock Processing
Check the box (if applicable): Indicates the nature of the operation is a livestock
processing farm / ranch.
TYPE OF FARM / RANCH
Nursery Stock
Check the box (if applicable): Indicates the nature of the operation is a nursery stock farm
/ ranch.
TYPE OF FARM / RANCH
Nuts
Check the box (if applicable): Indicates the nature of the operation is a nut farm / ranch.
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Section Name
Field Name
Field and/or Section Description
TYPE OF FARM / RANCH
Poultry
Check the box (if applicable): Indicates the nature of the operation is a poultry farm /
ranch.
TYPE OF FARM / RANCH
Tobacco
Check the box (if applicable): Indicates the nature of the operation is a tobacco farm /
ranch.
TYPE OF FARM / RANCH
Vegetables
Check the box (if applicable): Indicates the nature of the operation is a vegetable farm /
ranch.
TYPE OF FARM / RANCH
Vineyards
Check the box (if applicable): Indicates the nature of the operation is a vineyard.
TYPE OF FARM / RANCH
Other One
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Other Description One
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Other Two
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Other Description Two
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Other Three
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Other Description Three
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Other Four
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Other Description Four
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Describe Farm / Ranch Operations
Enter text: The text description of the operations of this risk or insured. As used here,
describe farm / ranch operations and any incidental business activities. Describe
additional items in optional type of farm / ranch checkboxes. The section should be
completed in enough detail to enable the underwriter to understand and classify each
operation.
LOSS HISTORY
Date of Occurrence One
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss One
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description of Occurrence One
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid One
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date of Occurrence Two
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Two
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description of Occurrence Two
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Two
Enter amount: The amount that has been paid on this claim to date.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY
Date of Occurrence Three
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Three
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description of Occurrence Three
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Three
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date of Occurrence Four
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Four
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description of Occurrence Four
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Four
Enter amount: The amount that has been paid on this claim to date.
PRIOR INSURANCE
INFORMATION
Prior Carrier One
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance One
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # One
Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION
Amount of Coverage One
Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION
Prior Carrier Two
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance Two
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # Two
Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION
Amount of Coverage Two
Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION
Prior Carrier Three
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance Three
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # Three
Enter identifier: The policy number of the previous coverage.
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Section Name
Field Name
Field and/or Section Description
PRIOR INSURANCE
INFORMATION
Amount of Coverage Three
Enter limit: The limit amount of the prior coverage.
OTHER RELATED
POLICIES
Insured Name One
Enter text: The named insured on other insurance.
OTHER RELATED
POLICIES
Type of Insurance One
Enter code: The line of business of the other policy.
OTHER RELATED
POLICIES
Policy # One
Enter identifier: The policy number on any other applicable insurance.
OTHER RELATED
POLICIES
Insured Name Two
Enter text: The named insured on other insurance.
OTHER RELATED
POLICIES
Type of Insurance Two
Enter code: The line of business of the other policy.
OTHER RELATED
POLICIES
Policy # Two
Enter identifier: The policy number on any other applicable insurance.
OTHER RELATED
POLICIES
Insured Name Three
Enter text: The named insured on other insurance.
OTHER RELATED
POLICIES
Type of Insurance Three
Enter code: The line of business of the other policy.
OTHER RELATED
POLICIES
Policy # Three
Enter identifier: The policy number on any other applicable insurance.
REMARKS
Remarks
Enter text: The general remarks associated with the farm policy. Use this section to
provide any additional information required for underwriting or rating. Attach additional
sheets if more space is required.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
LOCATION /
SUBLOCATION SCHEDULE Loc # One
Enter number: The producer assigned number of the location.
LOCATION /
SUBLOCATION SCHEDULE Bldg/Sublocation # One
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
LOCATION /
SUBLOCATION SCHEDULE Address One
Enter text: The first address line of the physical location.
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The second address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The city of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The state or province of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The postal code of the physical location.
LOCATION /
SUBLOCATION SCHEDULE Dwelling One
Check the box (if applicable): Indicates the structure is a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Structure One
Check the box (if applicable): Indicates the structure is other than a dwelling.
LOCATION /
SUBLOCATION SCHEDULEOther Type One
Check the box (if applicable): Indicates the structure is a type other than those listed.
LOCATION /
SUBLOCATION SCHEDULE Describe Other One
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
LOCATION /
SUBLOCATION SCHEDULE Range One
Enter text: The range of the insured location.
LOCATION /
SUBLOCATION SCHEDULE Latitude One
Enter text: The latitude of the insured location. This is the angular distance north or south
from the earth's equator measured through 90 degrees. The format of the data follows
The International Organization for Standardization 6709 and is sent as +/-XX.YYYYYYYY.
The GPS latitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Longitude One
Enter text: The longitude of the insured location. This is the arc or portion of the earth's
equator intersected between the meridian of a given place and the prime meridian and
expressed in degrees. The format of the data follows The International Organization for
Standardization 6709 and is sent as +/-XXX.YYYYYYYY. The GPS longitude coordinate.
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE Sublocation Description One
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it
from other sublocations at a given location. An example might be 3 story blue structure
on the left of the main building.
LOCATION /
SUBLOCATION SCHEDULE Loc # Two
Enter number: The producer assigned number of the location.
LOCATION /
SUBLOCATION SCHEDULE Bldg/Sublocation # Two
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
LOCATION /
SUBLOCATION SCHEDULE Address Two
Enter text: The first address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The second address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The city of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The state or province of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The postal code of the physical location.
LOCATION /
SUBLOCATION SCHEDULE Dwelling Two
Check the box (if applicable): Indicates the structure is a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Structure Two
Check the box (if applicable): Indicates the structure is other than a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Other Type Two
Check the box (if applicable): Indicates the structure is a type other than those listed.
LOCATION /
SUBLOCATION SCHEDULE Describe Other Two
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE Range Two
Enter text: The range of the insured location.
LOCATION /
SUBLOCATION SCHEDULE Latitude Two
Enter text: The latitude of the insured location. This is the angular distance north or south
from the earth's equator measured through 90 degrees. The format of the data follows
The International Organization for Standardization 6709 and is sent as +/-XX.YYYYYYYY.
The GPS latitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Longitude Two
Enter text: The longitude of the insured location. This is the arc or portion of the earth's
equator intersected between the meridian of a given place and the prime meridian and
expressed in degrees. The format of the data follows The International Organization for
Standardization 6709 and is sent as +/-XXX.YYYYYYYY. The GPS longitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Sublocation Description Two
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it
from other sublocations at a given location. An example might be 3 story blue structure
on the left of the main building.
LOCATION /
SUBLOCATION SCHEDULE Loc # Three
Enter number: The producer assigned number of the location.
LOCATION /
SUBLOCATION SCHEDULE Bldg/Sublocation # Three
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
LOCATION /
SUBLOCATION SCHEDULE Address Three
Enter text: The first address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The second address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The city of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The state or province of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The postal code of the physical location.
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE Dwelling Three
Check the box (if applicable): Indicates the structure is a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Structure Three
Check the box (if applicable): Indicates the structure is other than a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Other Type Three
Check the box (if applicable): Indicates the structure is a type other than those listed.
LOCATION /
SUBLOCATION SCHEDULE Describe Other Three
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
LOCATION /
SUBLOCATION SCHEDULE Range Three
Enter text: The range of the insured location.
LOCATION /
SUBLOCATION SCHEDULE Latitude Three
Enter text: The latitude of the insured location. This is the angular distance north or south
from the earth's equator measured through 90 degrees. The format of the data follows
The International Organization for Standardization 6709 and is sent as +/-XX.YYYYYYYY.
The GPS latitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Longitude Three
Enter text: The longitude of the insured location. This is the arc or portion of the earth's
equator intersected between the meridian of a given place and the prime meridian and
expressed in degrees. The format of the data follows The International Organization for
Standardization 6709 and is sent as +/-XXX.YYYYYYYY. The GPS longitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Sublocation Description Three
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it
from other sublocations at a given location. An example might be 3 story blue structure
on the left of the main building.
LOCATION /
SUBLOCATION SCHEDULE Loc # Four
Enter number: The producer assigned number of the location.
LOCATION /
SUBLOCATION SCHEDULE Bldg/Sublocation # Four
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
LOCATION /
SUBLOCATION SCHEDULE Address Four
Enter text: The first address line of the physical location.
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The second address line of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter text: The city of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The state or province of the physical location.
LOCATION /
SUBLOCATION SCHEDULE
Enter code: The postal code of the physical location.
LOCATION /
SUBLOCATION SCHEDULE Dwelling Four
Check the box (if applicable): Indicates the structure is a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Structure Four
Check the box (if applicable): Indicates the structure is other than a dwelling.
LOCATION /
SUBLOCATION SCHEDULE Other Type Four
Check the box (if applicable): Indicates the structure is a type other than those listed.
LOCATION /
SUBLOCATION SCHEDULE Describe Other Four
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
LOCATION /
SUBLOCATION SCHEDULE Range Four
Enter text: The range of the insured location.
LOCATION /
SUBLOCATION SCHEDULE Latitude Four
Enter text: The latitude of the insured location. This is the angular distance north or south
from the earth's equator measured through 90 degrees. The format of the data follows
The International Organization for Standardization 6709 and is sent as +/-XX.YYYYYYYY.
The GPS latitude coordinate.
LOCATION /
SUBLOCATION SCHEDULE Longitude Four
Enter text: The longitude of the insured location. This is the arc or portion of the earth's
equator intersected between the meridian of a given place and the prime meridian and
expressed in degrees. The format of the data follows The International Organization for
Standardization 6709 and is sent as +/-XXX.YYYYYYYY. The GPS longitude coordinate.
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Section Name
Field Name
Field and/or Section Description
LOCATION /
SUBLOCATION SCHEDULE Sublocation Description Four
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it
from other sublocations at a given location. An example might be 3 story blue structure
on the left of the main building.
PREMISES INFORMATION
Loc # One
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
County One
Enter text: The county of the location.
PREMISES INFORMATION
Section One
Enter text: The section of the insured location.
PREMISES INFORMATION
Township One
Enter text: The township of the insured location.
PREMISES INFORMATION
Farm Name One
Enter text: The full name of the location. As used here, enter the farm name used by the
applicant, if applicable.
PREMISES INFORMATION
# Acres One
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? Yes.
One
Check the box (if applicable): Indicates a Yes response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? No. One
Check the box (if applicable): Indicates a No response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Well One
Check the box (if applicable): Indicates the source of water is a well.
PREMISES INFORMATION
Pond/Lake One
Check the box (if applicable): Indicates the source of water is a pond or lake.
PREMISES INFORMATION
Hydrant Within 1,000 Feet One
Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000
feet.
PREMISES INFORMATION
Other One
Check the box (if applicable): Indicates the source of water is other than those listed.
PREMISES INFORMATION
Describe Other One
Enter text: The source of water for fire protection.
PREMISES INFORMATION
Less Than 1,000 Gallons One
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is under 1,000 gallons.
PREMISES INFORMATION
1,000-3,000 Gallons One
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is 1,000 - 3,000 gallons.
PREMISES INFORMATION
Over 3,000 Gallons One
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is over 3,000 gallons.
PREMISES INFORMATION
Prot Class One
Enter code: The fire rating protection class for this location. Note: some structures may
be located too far from the nearest hydrant, or too far from the nearest fire station, for the
protection class of the community to apply.
PREMISES INFORMATION
Fire District Code One
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
PREMISES INFORMATION
Fire District Name One
Enter text: The property's fire district name.
PREMISES INFORMATION
Operated By Applicant
Check the box (if applicable): Indicates the location is farmed by the applicant.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
Operated By Tenant
Check the box (if applicable): Indicates the location is farmed by a tenant.
PREMISES INFORMATION
Operated By Other Checkbox
Check the box (if applicable): Indicates the location is farmed by other than those listed.
PREMISES INFORMATION
Operated By Other Description
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Owned By Applicant Yes. One
Check the box (if applicable): Indicates the location / building is owned by the applicant.
PREMISES INFORMATION
Owned By Applicant No. One
Check the box (if applicable): Indicates the location / building is not owned by the
applicant.
PREMISES INFORMATION
Distance To Public Hydrant Ft One
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PREMISES INFORMATION
Distance To Fire Stat Mi One
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
PREMISES INFORMATION
Loc # Two
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
County Two
Enter text: The county of the location.
PREMISES INFORMATION
Section Two
Enter text: The section of the insured location.
PREMISES INFORMATION
Township Two
Enter text: The township of the insured location.
PREMISES INFORMATION
Farm Name Two
Enter text: The full name of the location. As used here, enter the farm name used by the
applicant, if applicable.
PREMISES INFORMATION
# Acres Two
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? Yes.
Two
Check the box (if applicable): Indicates a Yes response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? No.
Two
Check the box (if applicable): Indicates a No response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Well Two
Check the box (if applicable): Indicates the source of water is a well.
PREMISES INFORMATION
Pond/Lake Two
Check the box (if applicable): Indicates the source of water is a pond or lake.
PREMISES INFORMATION
Hydrant Within 1,000 Feet Two
Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000
feet.
PREMISES INFORMATION
Other Two
Check the box (if applicable): Indicates the source of water is other than those listed.
PREMISES INFORMATION
Describe Other Two
Enter text: The source of water for fire protection.
PREMISES INFORMATION
Less Than 1,000 Gallons Two
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is under 1,000 gallons.
PREMISES INFORMATION
1,000-3,000 Gallons Two
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is 1,000 - 3,000 gallons.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
Over 3,000 Gallons Two
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is over 3,000 gallons.
PREMISES INFORMATION
Prot Class Two
Enter code: The fire rating protection class for this location. Note: some structures may
be located too far from the nearest hydrant, or too far from the nearest fire station, for the
protection class of the community to apply.
PREMISES INFORMATION
Fire District Code Two
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
PREMISES INFORMATION
Fire District Name Two
Enter text: The property's fire district name.
PREMISES INFORMATION
Operated By Applicant
Check the box (if applicable): Indicates the location is farmed by the applicant.
PREMISES INFORMATION
Operated By Tenant
Check the box (if applicable): Indicates the location is farmed by a tenant.
PREMISES INFORMATION
Operated By Other Checkbox
Check the box (if applicable): Indicates the location is farmed by other than those listed.
PREMISES INFORMATION
Operated By Other Description
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Owned By Applicant Yes. Two
Check the box (if applicable): Indicates the location / building is owned by the applicant.
PREMISES INFORMATION
Owned By Applicant No. Two
Check the box (if applicable): Indicates the location / building is not owned by the
applicant.
PREMISES INFORMATION
Distance To Public Hydrant Ft Two
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PREMISES INFORMATION
Distance To Fire Stat Mi Two
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
PREMISES INFORMATION
Loc # Three
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
County Three
Enter text: The county of the location.
PREMISES INFORMATION
Section Three
Enter text: The section of the insured location.
PREMISES INFORMATION
Township Three
Enter text: The township of the insured location.
PREMISES INFORMATION
Farm Name Three
Enter text: The full name of the location. As used here, enter the farm name used by the
applicant, if applicable.
PREMISES INFORMATION
# Acres Three
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? Yes.
Three
Check the box (if applicable): Indicates a Yes response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? No.
Three
Check the box (if applicable): Indicates a No response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Well Three
Check the box (if applicable): Indicates the source of water is a well.
PREMISES INFORMATION
Pond/Lake Three
Check the box (if applicable): Indicates the source of water is a pond or lake.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
Hydrant Within 1,000 Feet Three
Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000
feet.
PREMISES INFORMATION
Other Three
Check the box (if applicable): Indicates the source of water is other than those listed.
PREMISES INFORMATION
Describe Other Three
Enter text: The source of water for fire protection.
PREMISES INFORMATION
Less Than 1,000 Gallons Three
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is under 1,000 gallons.
PREMISES INFORMATION
1,000-3,000 Gallons Three
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is 1,000 - 3,000 gallons.
PREMISES INFORMATION
Over 3,000 Gallons Three
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is over 3,000 gallons.
PREMISES INFORMATION
Prot Class Three
Enter code: The fire rating protection class for this location. Note: some structures may
be located too far from the nearest hydrant, or too far from the nearest fire station, for the
protection class of the community to apply.
PREMISES INFORMATION
Fire District Code Three
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
PREMISES INFORMATION
Fire District Name Three
Enter text: The property's fire district name.
PREMISES INFORMATION
Operated By Applicant
Check the box (if applicable): Indicates the location is farmed by the applicant.
PREMISES INFORMATION
Operated By Tenant
Check the box (if applicable): Indicates the location is farmed by a tenant.
PREMISES INFORMATION
Operated By Other Checkbox
Check the box (if applicable): Indicates the location is farmed by other than those listed.
PREMISES INFORMATION
Operated By Other Description
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Owned By Applicant Yes. Three
Check the box (if applicable): Indicates the location / building is owned by the applicant.
PREMISES INFORMATION
Owned By Applicant No. Three
Check the box (if applicable): Indicates the location / building is not owned by the
applicant.
PREMISES INFORMATION
Distance To Public Hydrant Ft
Three
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PREMISES INFORMATION
Distance To Fire Stat Mi Three
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
PREMISES INFORMATION
Loc # Four
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
County Four
Enter text: The county of the location.
PREMISES INFORMATION
Section Four
Enter text: The section of the insured location.
PREMISES INFORMATION
Township Four
Enter text: The township of the insured location.
PREMISES INFORMATION
Farm Name Four
Enter text: The full name of the location. As used here, enter the farm name used by the
applicant, if applicable.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
# Acres Four
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? Yes.
Four
Check the box (if applicable): Indicates a Yes response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Is there a year-round water supply
usable for fire protection? No.
Four
Check the box (if applicable): Indicates a No response to the question, Is there a year-
round water supply usable for fire protection?,
PREMISES INFORMATION
Well Four
Check the box (if applicable): Indicates the source of water is a well.
PREMISES INFORMATION
Pond/Lake Four
Check the box (if applicable): Indicates the source of water is a pond or lake.
PREMISES INFORMATION
Hydrant Within 1,000 Feet Four
Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000
feet.
PREMISES INFORMATION
Other Four
Check the box (if applicable): Indicates the source of water is other than those listed.
PREMISES INFORMATION
Describe Other Four
Enter text: The source of water for fire protection.
PREMISES INFORMATION
Less Than 1,000 Gallons Four
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is under 1,000 gallons.
PREMISES INFORMATION
1,000-3,000 Gallons Four
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is 1,000 - 3,000 gallons.
PREMISES INFORMATION
Over 3,000 Gallons Four
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is over 3,000 gallons.
PREMISES INFORMATION
Prot Class Four
Enter code: The fire rating protection class for this location. Note: some structures may
be located too far from the nearest hydrant, or too far from the nearest fire station, for the
protection class of the community to apply.
PREMISES INFORMATION
Fire District Code Four
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
PREMISES INFORMATION
Fire District Name Four
Enter text: The property's fire district name.
PREMISES INFORMATION
Operated By Applicant
Check the box (if applicable): Indicates the location is farmed by the applicant.
PREMISES INFORMATION
Operated By Tenant
Check the box (if applicable): Indicates the location is farmed by a tenant.
PREMISES INFORMATION
Operated By Other Checkbox
Check the box (if applicable): Indicates the location is farmed by other than those listed.
PREMISES INFORMATION
Operated By Other Description
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Owned By Applicant Yes. Four
Check the box (if applicable): Indicates the location / building is owned by the applicant.
PREMISES INFORMATION
Owned By Applicant No. Four
Check the box (if applicable): Indicates the location / building is not owned by the
applicant.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
Distance To Public Hydrant Ft
Four
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PREMISES INFORMATION
Distance To Fire Stat Mi Four
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
GENERAL INFORMATION
1. Does applicant have any other
business or other non-farm
activities on or off premises, such
as dude ranch, bed & breakfast or
resort facility? If so, include
receipts: $
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does applicant have any other business or other non-farm activities on or off
premises, such as dude ranch, bed & breakfast or resort facility?.
GENERAL INFORMATION
Receipts Amount
Enter amount: The total receipts amount for any other business or other non-farm
activities on or off premises, such as dude ranch, bed & breakfast or resort facility.
GENERAL INFORMATION
2. Is farming the primary source of
the insured's income?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is farming the primary source of the insureds income?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether farming is the primary source of the insured's
income.
GENERAL INFORMATION
3. Is this business new to the
agency?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the business new to the agency?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether business is new to the agency.
GENERAL INFORMATION
4. Has any policy been cancelled
or non-renewed in the past five (5)
years? (Missouri Applicants - Do
not answer this question)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Any policy or coverage declined, cancelled or non-renewed during the
mandated number of years?. As used here, this is not applicable in Missouri.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any policy has been cancelled or nonrenewed in
the past 5 years.
GENERAL INFORMATION
5. Have you inspected this
property in the last twelve (12)
months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you inspected this property in the last mandated time period?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has inspected this property in the
last twelve (12) months.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
6. During the last five years (ten in
RI), has any applicant been
indicted for or convicted of any
degree of the crime of fraud,
bribery, arson or any other arson-
related crime in connection with
this or any other property?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, During the mandated number of years, has any applicant been indicted for or
convicted of any degree of the crime of fraud, bribery, arson or any other arson related
crime in connection with this or any other property?. As used here, Rhode Island law
requires that all applicants for property insurance must answer this question.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any applicant has been indicted for or convicted
of any degree of the crime of fraud, bribery, arson or any other arson-related crime in
connection with this or any other property.
GENERAL INFORMATION
7. Are independent contractors
hired to perform any farming
operations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are independent contractors hired to perform any farming operations?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether independent contractors are hired to perform any
farming operations.
GENERAL INFORMATION
8. Is any part of the farm rented or
leased for recreations use?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Any part of farm used or leased for organized recreational use?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any part of the farm is rented or leased for
recreational use.
GENERAL INFORMATION
9. Are the farm premises open to
the public for activities such as
roadside stands, U-Pick,
recreational, camping, Rent-a-
Garden, auction, sales, shows,
rodeos, hay rides, fishing, kennels,
animal boarding, or Christmas tree
sales?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are the farm premises open to the public for activities such as, road side
stands, U-Pick, recreational, Rent-a-Garden, auction, sales, show, food, or beverage
service, hay rides, fishing, kennels, animal boarding, or Christmas tree sales uses?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the farm premises is open to the public for
activities such as roadside stands, u-pick, recreational, camping, rent-a-garden,
auction, sales, shows, rodeos, hay rides, fishing, kennels, animal boarding, or Christmas
tree sales
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
10. Are any portions of the farm or
structures rented or leased or
used by any other individual,
corporation or interest for other
than farming?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are any portions of the farm rented or leased or used by any other individual,
corporation or interest for other than farming?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any portions of the farm or structures are rented
or leased or used by any other individual, corporation or interest other than farming.
GENERAL INFORMATION
11. Does the applicant or spouse
own, rent or operate as a farm,
ranch or residence any premises
other than those described in the
premises information section.
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the applicant or spouse own, rent, or operate as a farm, ranch or
residence any premises other than those described in the premises information section?.
As used here, If yes, provide location and details of coverage as well as type of operation.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant owns, rents or operates as a farm,
ranch or residency any premises other than those described in the premises information
section.
GENERAL INFORMATION
12. Is any land held for real estate
development or speculation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is any land held for real estate development or speculation?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any land is held or real estate development or
speculation.
GENERAL INFORMATION
13. Does applicant maintain any
vacation or seasonal premises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does applicant maintain any vacation or seasonal premises?. As used here, if
yes, provide the address.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant maintains any vacation or seasonal
premises.
GENERAL INFORMATION
14. Is the applicant a subsidiary of
another?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is this company a subsidiary of another entity?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant is a subsidiary of another.
GENERAL INFORMATION
15. Does the applicant have
subsidiaries?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the applicant have subsidiaries? If yes, explain..
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has subsidiaries.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
16. Does the insured plan any
construction or renovation work to
be done on the premises in the
next twelve (12) months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the insured plan any construction or renovation work to be done on the
premises in the specified period of time?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the insured plans any construction or renovation
to be done on the premises in the next 12 months.
GENERAL INFORMATION
17. Is a formal safety program in
existence?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a formal safety program in existence?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is a formals safety program in existence.
GENERAL INFORMATION
18. Has applicant had a
foreclosure, repossession,
bankruptcy, judgment or lien
during the past five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien
during the past specified number of years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has had a foreclosure,
repossession, bankruptcy, judgement or lien during the past five years.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
REMARKS /
ATTACHMENTS
Remarks
Enter text: The general remarks associated with the farm policy. Use this section to
provide any additional information required for underwriting or rating. Attach additional
sheets if more space is required.
REMARKS /
ATTACHMENTS
Appraisals
Check the box (if applicable): Indicates an appraisal is attached to the policy.
REMARKS /
ATTACHMENTS
Bill of Sale
Check the box (if applicable): Indicates a bill of sale is attached to the policy.
REMARKS /
ATTACHMENTS
Cost Estimator
Check the box (if applicable): Indicates a cost estimator is attached to the policy.
REMARKS /
ATTACHMENTS
Inventories
Check the box (if applicable): Indicates an inventory is attached to the policy.
REMARKS /
ATTACHMENTS
Photos
Check the box (if applicable): Indicates a photograph is attached to the policy.
REMARKS /
ATTACHMENTS
Premises Diagram
Check the box (if applicable): Indicates a premises diagram is attached to the policy.
REMARKS /
ATTACHMENTS
State Supplements
Check the box (if applicable): Indicates a state supplement is attached to the policy.
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Section Name
Field Name
Field and/or Section Description
REMARKS /
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
REMARKS /
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
REMARKS /
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
REMARKS /
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
REMARKS /
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
REMARKS /
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
SIGNATURE
Applicant's Initials
Initial here: The named insured's initials.
SIGNATURE
Copy of the Notice of Information
Practices (checkbox)
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific
38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In
addition, ACORD 38 contains CA and MA state specific language.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) of the company(ies) listed on the document. This is required in most
states.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 401 (2013/09) rev. 06-28-2013
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