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LOUDOUN MUTUAL INSURANCE COMPANYWATERFORD, VAed 03 2022Agency:Agt Code:Request for Farmowners/Farm Fire QuoteEff DateExp DatePreliminary Underwriting Questions:If you answer “Yes” to any of the following questions, please contact Underwriting prior to completing the quote request:1. In the past 5 years, has any insurance been declined, cancelled, or non-renewed for this insured? Yes No2. Have there been any losses at any location for this organization in the past five years? Yes No3. Does applicant, co-applicant, resident of household, or tenant own or care for a pit-bull (American Staffordshireterrier) or variant thereof? Yes No4. Are there any non-farm operations conducted on premises? Yes No5. Are there any tenant operations on premises? Yes No6. Any woodstoves, pellet stoves, or space heaters used in detached structures? Yes NoNamed Ins’d:Mailing Add:Property Location(s) 1. (Acres)County:2. (Acres)County:3. (Acres)County:Page 1 of 5
Main Dwelling: ( Check here if no main dwelling)Occupancy: Owner Tenant OtherConstruction: Frame Other Masonry (minimum 2/3 masonry exterior to qualify)Prot Class: Protected (1-8) Unprotected (10)Protective Devices: Partially Protected (9) Suburban (Preferred or MasterGuard only; w/in 6 mi to FD; visible from road)Smoke AlarmsDwelling Coverage LimitDead Bolts DedOther:Year Built:Update year: Electric Plumbing Heating RoofPolicy Form: BasicRating Tier: Standard Preferred* ( 100K minimum Cov A; 60 yrs old) MasterGuard* ( 400K minimum Cov A; 40 yrs old) Broad Special Tenant (form 4)Endorsements: Farm Guardian* (recommended)ID Recovery*Inland Flood 10,000Inland Flood 25,000 Equipment Breakdown*Inland Flood 50,000Other Property Endorsements:*available for owner occupied dwellings onlyLiability:Limit 100,000 300,000 500,000 1,000,000Med Pay 1,000 3,000 5,000Endorsements:Add’l Residence Rented to Others(No. of Families) Add’l Farm Premises Rented to Others Employers Liability: Full Time Part Time (41 – 179 days) Part Time (40 days or less)(Recommendation: Always include Employers Liability if Workers Comp not required) Equine Liability: No. of horses on premisesNo. involved in training operationNo. involved in breeding operationReceipts from riding instruction Unlicensed Farm Truck(s) over 35,000 lbs: Data Compromise Coverage ( 50,000 limit; 1000 deductible)Other Liability Endorsements:Page 2 of 5(description)
Please list and describe the type of farming on premises ( Dairy, Beef, Poultry, Wool, Produce, Equine, Vineyard, Exotic Animals,etc ):Machinery: Scheduled (Schedule Total) (attach copy of current schedule, if possible)) Blanket (Amount(Recommendation: Schedule larger items for the better rate.)Livestock:Note: For Livestock, there is no Blanket cov’g option. There is also no deductible, but there is an 80% coinsurance clause.Number of HeadValue Per HeadType of Livestock Include Additional Perils Include Winter PerilsFarm Structures (Barns, Silos, etc.):(See footnotes below for further explanation of certain items. If more than 5 items, list others under Other Items/Comments)AmountLoc #Description1Frame,Masonry,MetalPage 3 of 52Type1, 2 or 33RC orACV?BasicPerilsSpecialPerils4Wt ofSnowPerils5
Farm Dwellings (Tenant Dwellings):(See footnotes below for further explanation of certain items. If more than 5 items, list others under Other Items/Comments)AmountLoc#1Description (include year built and updateinformation – electric, plumbing, heating, androof)Coverage G (Unscheduled Farm Personal Property):2Frame,TypeMasonry, 1, 2Metalor 33RCorACVBasicPerilsSpecial4PerilsWt ofSnowPerils5 Amount ( 5,000 included in LM-20 & LM-199)Mortgagee or Lienholders: Mortgagee billedInsured billed: Quarterly, Semi-Annual, or AnnualACH (separate form required)Other Items/Comments:1Differentiate descriptions as distinctly as possible. Include measurements when known.2Barns: Type 1 Excellent condition; 25K minimum; 1-story maximum; masonry foundation or padType 2 Good condition; 10K minimum; masonry foundation or padType 3 Fair condition; 1K minimum; hay storage allowedDwg:Type 1 50K minimum; 30 years oldType 2 25K minimum; 50 years oldType 3 other3For RC, must be in excellent condition; fully enclosed building; roof pitch of at least 4/124For Special Perils, must be in excellent or good condition5For Wt of Snow Perils, must be in excellent or good condition (Type 1 or 2); minimum 4/12 roof pitch; and not over 50 ft wide.6 Protected, Partially Protected, and UnprotectedProt. 6ClassPage 4 of 5
Basic Underwriting Questions - For Quoting Purposes OnlyNote: These questions are NOT a substitute for the complete set ofunderwriting questions required later in risk evaluation process.1. Prior Carrier:2. Are woodstoves used in any dwellings or other buildings?3. Insured’s SSN and date of birth:(Credit & loss history checks help us better determine IRPM quote adjustment.)4. If known, what is the existing policy premium, or that of a competing quote?5. Please list any other information that you feel may help us better quote this risk.Upon completion, email or fax this form to us and we will return a quote and blank application as quickly as possible.Thank you for allowing Loudoun Mutual the opportunity to quote this risk.Page 5 of 5
LOUDOUN MUTUAL INSURANCE COMPANY ed 03 2022 . WATERFORD, VA . Agency: Agt Code: Eff Date _ Exp Date . Preliminary Underwriting Questions: If you answer "Yes" to any of the following questions, please contact Underwriting prior to completing the quote request: 1. In the past 5 years, has any insurance been declined, cancelled, or non .
