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Farm Insurance, Crop Insurance, Ag Insurance

Ag Insurance can take many forms. We are happy to look at any coverage you need. Simple fill out this form and send it to us.

Print Form - Print and Complete

Online Form - Complete Online

Name Of Applicant:
Principal Business Address:
Pest Control License Number:
Other License Numbers and Descriptions:
Professional Staffing #:
Owners and Partners #:
Projected Annual Receipts:
Employees That Are Licensed Applicators #:
Unlicensed Employees #:
Any Prior Claims of Losses Paid:

If Yes, Please Provide Details:
Are All Licensed Staff Current On Their Continuing Education:

If No, Please Explain:
Does The Applicant: Spray Both Pesticides and Herbicides?
Utilize Separate Tanks For Pesticides and Herbicides?
Use "Air-Induction Nozzles" for Herbicide Work?
Use ONLY Chemical Resistant Hoses?
Use ONLY Stainless Steel Tanks?
Does The Applicant Utilize Fumigation?

If Yes, List The Crops and/or Commodities Fumigated and Chemicals Used:
Are "Restricted Use" Chemicals Used?

If Yes, List The "Restricted Use" Chemicals:
What Non-Restricted Use Chemicals Are Primarily Used?
Does The Applicant Sell Chemicals?

If Yes, List The Chemicals:
Does The Applicant Manufacture of Sell any "Custom Mix" Chemicals?

Does The Applicant Apply Chemicals in a "Research Capacity" On Small Plots?

If Yes, Fully Describe This Operation:
Is The Applicant A Current Member Of A Trade Group or Professional Association?

If Yes, List The Name Of The Group:
How Many Acres Does The Applicant Expect To Spray/Treat On An Annual Basis?
Does The Applicant Enter Into Any Insured Contracts Under Which He Would Assume The Tort Liability Of Another Party?

I understand that misrepresentation or omission of materials facts will be cause for cancellation and many void coverage.
Initials Of Applicant:
Security Code: