Intact Insurance Company

FIP app (07.2012) - 78568 Page 1 of 4

Farm Insurance Protector Application

Broker: / Broker #: / Billing Method: Broker BillEasipay 1Easipay 3Easipay 12
Policy Number / Policy period / Day / Month / Year / Day / Month / Year / 12.01 a.m. Standard Time at the postal address of the applicant as stated herein
From / To
Name and Mailing Address of Applicant / Mortgagee or Loss Payee Name and Address
Loc. 1:
Loc. 2:
Legal Address / Loc. 1: / Loc. 2:
Risk Contact / Name of Contact at Risk: / Telephone Number of Contact at Risk:
If the applicant is a Corporation/Association/Joint Venture/Partnership - provide name(s) of principal(s):
Dwelling Rating Information – check all appropriate spacesNote: Photos are Required Of Dwelling and Outbuildings.
Insured’s Date of birth (if applicable): (dd/mm/yyyy)
1. Occupancy / 2. Structure Type / 3. Construction Type / 4. Year Built #
Loc. 1 / Loc. 2 / Loc. 1 / Loc. 2 / * Must be fully described in Remarks Section and Photos sent with the Application / Loc. 1 / Loc. 2 / Brick = B
Cement = C
Frame = F
Masonry Veneer = MV
Brick Veneer = BV
Vinyl Veneer = VV
If not one of the above, please give details in Remarks Section. / Loc. 1 / Loc. 2
Yes
No / Yes
No / Principal Residence / Detached*Mobile Home / Detached*Mobile Home
Yes
No / Yes
No / Seasonal Residence / Detached*Mobile Home / Detached*Mobile Home
Yes
No / Yes
No / Owner Occupied / 5. Protection / Primary / 6. Heating / Auxiliary
Yes
No / Yes
No / Tenant Occupied / Loc. 1 / Loc. 2 / Loc. 1 / Loc. 2 / Loc. 1 / Loc. 2
Yes
No / Yes
No / Occupied by Hired Hand / Unprotected / Yes
No / Yes
No / Yes
No / Yes
No / Furnace (Central) / Yes
No / Yes
No
Yes
No / Yes
No / Commercial Occupancy / Within 300 m of a hydrant / Yes
No / Yes
No / Yes
No / Yes
No / Comb. with wood / Yes
No / Yes
No
Yes
No / Yes
No / Unoccupied Vacant / Within 8 km. of a fire hall / Yes
No / Yes
No / Yes
No / Yes
No / Comb. W/O wood / Yes
No / Yes
No
Yes
No / Yes
No / Under Construction / Within 16 km. of a responding firehall at: / Yes
No / Yes
No / Yes
No / Yes
No / *Wood burning unit
* Solid fuel heating questionnaire is required / Yes
No / Yes
No
Other – Describe / Electrical Wiring:
Copper Aluminium Copper + Aluminium / Yes
No / Yes
No / Approved space heater / Yes
No / Yes
No
Yes
No / Yes
No / Electric / Yes
No / Yes
No
# If constructed over 20 years ago, indicate year the following were last renewed / Year / Loc. 1 / Loc. 2
If partial upgrading, describe in Remarks (must accompany application). Remarks: / Electrical
Heating
Plumbing
Roofing
Age of Water Heater/when last installed
Additional Liability Exposure InformationExplain “Yes” responses in remarks
Location rented to others Yes No # weeks
Additional families Yes No #
Rooms rented to others Yes No #
Total acreage owned and rented by Insured?
Total acreage leased to others? Used For?
Bed and breakfast. Number of guests
Horse Boarding only – Number
Horse Boarding and Training – Number of Horses / Additional residences/properties Yes No # of properties
# of units (indicate locations in remarks)
Day-care # of children Licensed No Yes
Business activities or custom work Type
Gross receipts $
Watercraft Number Type
MPH HP Length feetmetres
Summary of Coverages
Coverage Type / Property coverages / Liability / Options / Premium
Loc. / Specify the coverage type desired for each location / Ded. / A
Dwelling / B Private Structures / C Personal Property / D Loss of Use of Your Dwelling / Section III Farm Liability / Water Damage / Glass / Earth
quake
1 / 1Comprehensive Farmowners
2Broad Farmowners
3Tenants Package Comprehensive
4Tenants Package Standard
5Seasonal Farmowners Broad / $500
$1,000 / $ / $ / $ / See policy wording for details. / $500,000
$1,000,000
$2,000,000 / $
2 / 6Seasonal dwelling Fire & E.C.
7Rented Dwelling Comprehensive
8Rented Dwelling Named Perils
9Vacation Trailer/Camper Unit
10 / $500
$1,000 / $ / $ / $ / F Medical Payments
$5,000 Each Person
$25,000 Per Accident / Included
Scheduled Property Floater (Personal Articles)Attach additional schedules if necessary
Description (attach Bill of Sale or Appraisal if value is over $3,500 for Furs and Fur Garments, $4,000 for Jewellery, Watches and Fine Arts) / Cost / Year bought / Amount of Insurance / Deduct. / Rate / Premium
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
$ / $ / $ / $
Boat and Motor Floater Coverage / All Risk / Named Perils
Length / Year / Description / H.P. / M.P.H. / Serial Number / Limit / Deduct. / Rate / Premium
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Vacation Trailer/Camper Unit Floater Coverage All Risk
Length / Year / Description / Serial Number / Limit / Deduct. / Rate / Premium
$ / $ / $
$ / $ / $
Liability and Underwriting Information – This section Must be completed
Farm Revenue: Less than $15,000 Less than $100,000
Less than $250,000 Greater than $250,000 / Pick your ownRevenue $
Ladder suppliedYes No
Does Insured have dogs? Yes No If yes, what breeds?
Other Liability Exposures / How many months of the year is the property normally occupied by the insured? Loc. 1 Loc. 2

Security Systems

Fire Yes No Local Monitored / Monitored By:
BurglarYes No Local Monitored / Monitored By:
SprinklersYes No Local Monitored / Monitored By:
Smoke DetectorsYes No Number / Type:
Farm Property Schedules
Type of Farm (Check Main Source of Revenue)
Cash Crops / Dairy # of Head / Hog # of Hogs / Hobby
Fruits/Vegetables / Beef # of Head / Horse # of Horses / Livestock Sales to US? Yes No
If yes, what are receipts?
Describe all Farm Operations:
Number of years farming: / Specify any occupation(s) other than farming:
Loss Payee
Name, Address and Postal Code / Interest in Item # / Nature of Interest
Dwelling / Outbuilding / Loss Payee / Lienholder
Livestock / Equipment / 1st. Mortgagee / 2nd. Mortgagee
Name, Address and Postal Code / Interest in Item # / Nature of Interest
Dwelling / Outbuilding / Loss Payee / Lienholder
Livestock / Equipment / 1st. Mortgagee / 2nd. Mortgagee

Farm Outbuildings (90% Co - insurance) and Contents

I Form1Broad Form2 Named Perils

/

II DeductibleA $500B $1,000

/

BlanketScheduled

IIIType

AMetal Construction, approved foundation, no heat
BMetal Construction, approved foundation, approved heat
CFrame Construction, approved foundation, no heat
DFrame Construction, approved foundation, approved heat
EGrain storage only, frame or metal, no heat approved concrete foundation
FPole barns, Corrals, Animal shelters, Hay sheds
GBunkhouses, Pump houses and other buildings not otherwise described. Approved wood heat /

HDairy Barns

IHog Barns
JGrain and Seed Cleaning Buildings
KElevators (no cleaning or processing)
LP.M.U. barns
MWindmills, Wind pumps and Towers, Light poles and wiring, Orchard Wind Machines
Bldg # / I / II / III / Building Description and Occupancy / Year Built / Heat / Size / Limit of Insurance / Repl. Cost / Rate / Premium
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Farm Machinery, Equipment & Tools - $500 Deductible
  1. TypeA.Scheduled EquipmentD.PivotsG.Stock Trailer
B.Blanket EquipmentE.Irrigation EquipmentH.Loss of Use ($10,000 Limit)
C.Grain DryersF.Miscellaneous Tools (Max. $1,000 any one item)I.ATV’s
Type /

Year

/

Make & use

/

Model #

/

Serial Number

/

Limit of Insurance

/

Loss of use limit

/

Rate

/

Premium

$

/

$

$

/

$

$

/

$

$

/

$

$

/

$

$

/

$

$

/

$

$

/

$

What is the estimated maximum value of machinery stored in one building? $ Identify building:
Farm Livestock Floater – Broad Named Perils Form
IA.Range Cattle, SheepB.Dairy Cattle, P.M.U. Horses C.Hogs, Llamas, Elk, BuffaloD.Pleasure Horses E.Show horses

I

/ Description / Number of Animals / Max. Value Per Head / Limit of Insurance / Rate / Premium
$ / $ /

$

$ / $ /

$

$ / $ /

$

$ / $ /

$

$ / $ /

$

Grain , Feed, Fertilizer, Chemicals & Produce – $500 Deductible
IForm
  1. Fire and lightning (1000)
  2. Broad Named Perils (5032)
/ II Type
AFeed, Hay, Straw Fodder and Silage (chose A or B under I Form)
BGrain, Seeds D.Farm products & supplies not kept in specialized
Buildings.
C.Chemicals & Fertilisers E.Farm products & supplies kept in specialized Buildings

I

/ II / Description / Building Where Stored / Limit of Insurance / Rate / Premium
$ /

$

$ /

$

$ /

$

$ /

$

The Following Questions Should Be Answered by the Applicant and the Application Then Signed by yhe Applicant.
Has any Insurer declined an application, cancelled or refused to renew or restricted coverage on a policy from this applicant or any member of his/her family residing with him/her?
Yes No If “YES”, please advise DATES and NAMES of Insurers in REMARKS / Has the applicant or any member of his/her family residing with him/her sustained any losses during the past five years?
Yes No If “YES”, please advise DATES and NAMES of Insurers in REMARKS
Previous Insurer: / Policy Number:
ENTERPRENEURIAL Stability Indicator Information
Name of Owner: / Date of Birth of Owner:
Address of Owner’s Principal Residence including Postal Code:
Number of Years the Owner has lived at this address? / Number of Years the Owner has been operating this business?
Details of other Insurance policies presently in force with ING (e.g. home or automobile or other business policies)
Remarks:

Disclosure

Where(A) An applicant for this contract gives false particulars to the prejudice of Intact Insurance Company or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or
(B)the insured contravenes a term of the contract or commits a fraud; or
(C)the insured wilfully makes a false statement in respect of a claim, a claim will become invalid and the insured’s right to recovery is forfeited.
In order to prepare the most advantageous offer and to provide insurance coverage with respect to this application, any renewal, or change in coverage, the broker and insurer may collect, use and disclose your personal information as permitted by law for the purposes necessary to assess the risk, investigate and settle claims, and detect and prevent fraud, such as credit information, driving record information and claims history.
Signature of Applicant / Date:
(dd/mm/yyyy) / Signature of Applicant / Date:
(dd/mm/yyyy)

Premium Summary

/ % / Discount/Surcharge / Premium
Discounts – Describe which cover it applies to / $ / Total Dwelling Premium / $
$ / Miscellaneous Coverage Premium / $
$ / Outbuilding Premium / $
$ / Farm Equipment Premium / $
Total Amount / $ / Farm Livestock Premium / $
Surcharges – Describe which cover it applies to / $ / Grain Coverage Premium / $
$ / Farm Liability Premium / $
$ / Subtotal / $
$ / Less discounts / $
$ / Plus surcharges / $
Total Amount / $ / Total Policy premium / $
Broker Report
How long has the applicant been personally known to you?
Number of years? / Describe housekeeping:
On what date did you last inspect the premises? / Fuse panel Yes No 100amp Breakers No
Is panel over fused? Yes No
What is the general condition of farm buildings? Excellent Good Average Fair Poor
Do you recommend this risk Yes No.
Signature of broker______Date: ______

FIP app (07.2012) - 78568 Page 1 of 4