"*" indicates required fields Who is filling out this form?ClientAgentHow did you hear about us?FacebookGoogleRadioAdvertisementReferralWord of MouthWho referred you? First Last Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email:* Cell Phone Number* Farm DetailsFarm Business Name*FEIN / Tax-ID Number:If applicable Business Type:LLCCorporationNonprofitSole ProprietorshipPartnershipIs your Farm Address different from your contact address above?YesNoFarm Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please Describe Farming Operations:Gross Receipts (if none, please state)Total Payroll (if none, please state)Number of Full Time Employees (if none, please state)Number of Part Time or Seasonal Employees (if none, please state)Is Farming your major source of income?YesNoIf no to the above question, please explain:Total Number of Acres:Percentage farmed:Acres Owned by You (if none, please state)Acres You Lease to Others (if none, please state)Attach loss runs & any other relevant files on your policy Drop files here or Select files Max. file size: 98 MB. Consent I agree to the privacy policy.
