CSIO Farm Application

ADDITIONAL COVERAGES LIMIT DEDUCTIBLE PREMIUM

FIRE FIGHTING CHARGES

OTHER (SPECIFY)

ARE YOU EXEMPT FROM:

GST PST RST HST

TOTAL

PREMUIUM SUMARY PREMIUM

TOTAL FROM HABITATIONAL APPLICATION (IF APPLICABLE)

ADDITIONAL RESIDENCES

- BUILDING

OUTBUILDINGS

- CONTENTS

FARM PROPERTY

LIVESTOCK

CHEMICALS & FERTILIZERS, FODDER, GRAIN AND PRODUCE

OTHER (SPECIFY)

OTHER (SPECIFY)

FARM INSURANCE APPLICATIONCSIO ENGLISH

NOT ALL COVERAGES LISTED ON THIS FORM MAY

BE AVAILABLE. PLEASE REFER TO YOUR AGENT,

BROKER AND/OR COMPANY.FRENCH

TO BE USED IN CONJUNCTION WITH CSIO HABITATIONALFORM IF INSURING PRIMARY RESIDENCE

INSURANCE COMPANY POLICY NUMBER NEW REPLACING POL. NO.

APPLICANT’S FULL NAME AND POSTAL ADDRESS (FIRST NAME/LAST NAME)(COMPLETE IF NOT ATTACHING HABITATIONAL APPLICATION)

CSIO FARM (10/03)

BROKER CLIENT ID

BROKER/AGENT CODE

POSTAL CODE

© 2003, Centre for Study of Insurance Operations. All rights reserved.

TYPE OF FARM (CHECK MAIN SOURCE OF REVENUE)

BROKER/AGENT BILL CREDIT CARD #

COMPANY BILL OTHER (SPECIFY)

PAYMENT PLAN WITHDRAWAL DATE ( )YYYY/MM/DD

CONTACT NUMBER CONTACT NUMBERPHONE

FAX

EMAIL

LEGAL LOCATION(S):( I.E. #, LOT, CONCESSION, TWP, COUNTY QUARTER, SECTION, TWP, RANGE, MERIDIAN)OR

POLICYPERIOD

ALL TIMES ARE LOCAL TIMES AT THEAPPLICANT’S POSTAL ADDRESSt

TIME DATE DATEMM MMYYYY YYYYDD DD

FROM

A.M. P.M.

TO 12:01 A.M.

CASH CROPS

DESCRIBE ALL FARM OPERATIONS

OTHER (SPECIFY)

LIMITED POLLUTION

LIABILITY

ESTIMATED TOTAL

LESS DISCOUNTS

PLUS SURCHARGES

NATURE OF INTEREST INTEREST IN ITEM #

INTEREST IN ITEM #

INTEREST IN ITEM #

NAME, ADDRESS AND POSTAL CODE



NATURE OF INTEREST

NATURE OF INTEREST

LOSS PAYEE DWELLING

DWELLING

DWELLING

LOSS PAYEE

LOSS PAYEE

1 MORTGAGEEst LIVESTOCK

LIVESTOCK

LIVESTOCK

1 MORTGAGEEst

1 MORTGAGEEst

LIENHOLDER OUTBUILDINGS

OUTBUILDINGS

OUTBUILDINGS

LIENHOLDER

LIENHOLDER

2nd MORTGAGEE EQUIPMENT

EQUIPMENT

EQUIPMENT

2nd MORTGAGEE

2nd MORTGAGEE

LOSS PAYEE

ESTIMATED POLICY PREMIUM

DAIRY HOG HOBBY TOBACCO FARM #

FRUIT/VEG BEEF POULTRY HORSE OTHER

DISCOUNTS / SURCHARGES - DESCRIBE % $

DISCOUNTS

SURCHARGES

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CSIO FARM (10/03)

LIVESTOCK

LIVESTOCK OPTIONAL EXTENSIONS

SPECIALTY (I.E. POULTRY, SWINE)

ITEM#

ITEM#

ITEM#

LOC#

LOC#

LOC#

BLDG#

BLDG#

BLDG#

COVCODE

COVCODE

REGISTEREDY / N

# OFHEAD

YEAROF

BIRTH

AVGLIMITPER

HEAD

AVERAGEVALUE

# OF CULTIVATEDAREAS

DEDUCTIBLE

DEDUCTIBLE

DEDUCTIBLEVALUE IN(000’s)

VALUE OUT(000’s)

TOTALVALUE OUT

(000’s)

RATE

RATE

RATE

TOTAL

TOTAL

TOTAL

PREMIUM

PREMIUM

PREMIUM

AMOUNT OFINSURANCE

AMOUNT OFINSURANCE

AMOUNT OFINSURANCE

# OFWEEKS

# OFANIMALS

(000’s)

MONTHLYREPORT

MONTHLYREPORT

ITEM / DESCRIPTION / TYPE

ITEM / DESCRIPTION / TYPE

TYPE

LOADING / UPLOADING

PARTIAL MORTALITY

ALARM NO YES

DETAILS: DETAILS:

CONSEQUENTIAL LOSS

HEAT PROSTRATION

ENTRAPMENT

OTHER

GENERATOR NO YES AUTOMATIC MANUAL

ATTACK BY WILD ANIMAL

OTHER

COV - COVERAGE CODES:

COV - COVERAGE CODES:

SCHEDULEDBLANKET1. FIRE 3. OTHER

2. NAMED PERILS

1. COMPREHENSIVE 3. FIRE ONLY

2. FIRE & EXTENDED COVERAGE 4. OTHER

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CHEMICALS & FERTILIZERS, FODDER,GRAIN AND PRODUCECSIO


FARM PROPERTY (MACHINERY, EQUIPMENT, TACK, TOOLS, MISC.) COV - COVERAGE CODES:


2. FIRE & EXTENDED COVERAGE 4. OTHERSCHEDULEDBLANKET

CSIO

BLANKET LOSS OF USE LIMIT REQUIRED $

YEAR MAKE MODEL SERIAL NUMBER DEDUCTIBLE RATE PREMIUMCOV

CODE

RC

ACV

CUSTOM USE( )4

LOSS OFUSE LIMIT

AMOUNT OFINSURANCE

DESCRIPTION OF EQUIPMENT

TOTAL

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ITEM#

LOC#

BLDG#

CSIO FARM (10/03) © 2003, Centre for Study of Insurance Operations. All rights reserved.

OUTBUILDINGS AND CONTENTSCOV - COVERAGE CODES:


2. FIRE & EXTENDED COVERAGE 4. OTHER

TYPEWOOD-STOVE

Y / N

DEDUCTIBLEAMOUNT OFINSURANCE

RATE PREMIUM

BUILDING TYPE AND NAME DIMENSIONS CONST.YEARBUILT

OCCUPANCYCOV

CODEFOUNDATION

TYPEAMPS

ELECTRICAL HEATING RATING

YR UPDATEDFULL / PARTIAL

ITEM#

ITEM#

BUSUINESS INTERRUPTION (BI)

LOC#

BLDG#

EARN-INGS

PROFITS NOCO

DEDUCTIBLE AMOUNT OFINSURANCE

RATE PREMIUM

TOTAL DISCOUNTS

TOTAL SURCHARGES

LOC#

BLDG#

TOTAL

DISCOUNT / SURCHARGES - DESCRIBE

DISCOUNTS

SURCHARGES

SUBTOTAL

LESSDISCOUNTS

PLUSSURCHARGES

PLUS BI

TOTAL

SCHEDULEDBLANKET

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CSIO


EMPLOYER’S LIABILITY

ADDITIONAL CHARGES

ADDITIONAL INSURED

CROSS LIABILITY

BOARDING OF LIVESTOCK NO. OF ANIMALS TYPE OF LIVESTOCK

STABLEMAN’S LIABILITY (CCC) AGGREGATE PER OCCURRENCE PER ANIMAL

TENANT’S LEGAL LIABILITYLOCATION(S)

LOCATION # AMOUNT

LOCATION # AMOUNT

RATEABLE PAYROLL

NON-OWNED AUTO

VOLUNTARY COMPENSATION

WATERCRAFT (REFER TO HABITATIONAL FORM FOR DETAILS)

VEHICLES -

UNLICENSED

YEAR

YEAR

TYPE

TYPE

MAKE

MAKE

MODEL

MODEL

SERIAL NO.

SERIAL NO.

CC

CC

H.P.

H.P.

ADDITIONAL

EXPOSURE -

SPECIFY

CHECK ANY OF THE FOLLOWING PRESENT ON THE PREMISES OR PRACTICED BY THE APPLICANT(S) OR ANY HOUSEHOLD MEMBER(S) OR TENANT(S):

REVENUE

CHECK ALL THAT ARE APPLICABLE AND INDICATE ANNUAL REVENUE REVENUE

TOTAL

LIABILITY LIMIT $

AGGREGATE LIMIT $

PROPERTY DAMAGE DEDUCTIBLE $

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LIABILITY SECTIONCSIO

LIABILITY AND LOCATIONS - OWNED, LEASED TO OR OPERATED BY THE NAMED INSURED

EXPOSURE & HAZARDS

LOC.#

FARM USE OWNED RENTED

TOTAL

ACERAGE PREMIUMLEGAL LOCATION(S);(I.E.#, LOT, CONCESSION, TWP, COUNTY, OR QUARTER, SECTION TWP, RANGE, MERIDIAN)

BED & BREAKFAST

BOARDING

CUSTOM FARMING

DAYCARE / BABYSITTING

HAY / SLEIGH RIDES

PICK YOUR OWN

NO. OF GUESTS PER YEAR

SPECIFY TYPE AND NO.

NO. OF CHILDREN

NO. PER YEAR ON PREMISES OFF PREMISES

LADDER SUPPLIED? YES NO

SPECIFY

ROADSIDE STAND

SALE OF WOOD/MAPLE SYRUP

SALES BARN

SNOW REMOVAL

TRAIL RIDES

OTHER

CSIO FARM (10/03)

ALL TERRAIN VEHICLES GRAVEL PIT PONDS,RIVERS, SWIMMING POOLS

AUCTIONS HORSE PULLS RIDING ARENA

BOARDING/LEASING LIVESTOCK / PETS HORSE TRACK SHOW ANIMALS

LESSONS STABLEMAN’S LIABILITYCUSTOM SPRAYING

MOTORIZED VEHICLE TRACKS/TRAILS UNUSUAL ANIMALSDOG

PERSONAL WATERCRAFT VEHICLE / BOAT STORAGE

BUSINESS PERSUIT:

(EXPLAIN)

FISHING

PETTING ZOO OTHER

U.S. EXPOSURE YES NO

SPECIFY


LIABILITY LIMIT $

AGGREGATE LIMIT $

PROPERTY DAMAGE DEDUCTIBLE $

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LIABILITY SECTIONCSIO

FARMERS LIMITED POLLUTION LIABILITY

TANK DATA SUPPLEMENT

DO YOU APPLY PESTICIDES, INSECTICIDES, CHEMICAL FERTILIZERS, OR HERBICIDESAWAY FROM THE PREMISES YOU OWN, RENT OR LEASE? (OTHER THAN ANEIGHBOURLY EXCHANGE OF LABOUR)

DO YOU PROCESS OR SELL ANY CHEMICALS (FERTILIZERS, PESTICIDES, ETC.)OR STORE CHEMICALS FOR OTHER THAN YOUR OWN USE?

DO YOU PERFORM ANY PROCESSING OPERATIONS INVOLVING CHEMICALSOTHER THAN FOR YOUR OWN USE?

DO GROSS RECEIPTS FROM CUSTOM FARMING EXCEED YOUR OTHERFARMING INCOME?

DO YOU EVER USE OR STORE POLYCHLORINATED BIPHENYLS (PCB’S)? (OTHERTHAN THOSE IN HYDRO TRANSFORMERS IN CURRENT USE)?

1) IS THERE A WRITTEN TANK FILLING PROCEDURE CONTAININGINFORMATION TO PREVENT SPILLS OR OVERFLOWS?

INFORMATION IS REQUIRED ON ALL TANKS

ARE THERE ANY GOVERNMENT STATUTES, STANDARDS, OR REGULATIONS(FEDERAL, PROVINCIAL, MUNICIPAL) FOR THE PROTECTION OF THE ENVIRONMENTWITH WHICH TO YOUR KNOWLEDGE YOU DO NOT COMPLY?

CLAIM OR LOSS EXPERIENCE: HAVE THERE BEEN ANY POLLUTION ORENVIRONMENTAL OCCURRENCES IN THE PAST FIVE YEARS?

DO YOU HAVE STORAGE TANKS WITH MORE THAN 500 GALLON CAPACITY?(IF YES, COMPLETE TANK DATA SUPPLEMENT)

HAS ANY POLLUTION LIABILITY COVERAGE BEEN DECLINED IN THE PAST, OR DOYOU HAVE ANY COVERAGE CURRENTLY IN EFFECT?

ARE THERE ANY CREEKS, RIVERS, OR OTHER BODIES OF WATER ON THE PREMISESYOU OWN, RENT, LEASE, OR DO WORK ON?

2) IS THERE A WRITTEN EMERGENCY PROCEDURE OUTLINING ACTIONSTO BE TAKEN IN THE EVENT OF A TANK SPILL OR OVERFLOW ?

YES NO

YES NO

YES NO

YES NO

LOC.#

DIAGRAM

SHOW ALL BUILDINGS, THEIR DIMENSIONS AND OCCUPANCY (INSURED OR NOT) WITH DISTANCE BETWEEN EACH BUILDING. SHOW FUEL STORAGE LOCATION.

TANK#

PRODUCT STOREDCAPACITY

(IN 1000 LITRES)ABOVE OR BELOW GROUND

IF ABOVE GROUND, IS ITDYKED?

INDOORS OROUTDOORS

CONSTRUCTIONYEARBUILT YES NO

HIGH LEVEL ALARM

NORTH


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ACKNOWLEDGEMENTSCSIO

LOSS & POLICY HISTORY

HAVE THERE BEEN ANY LOSSES OR CLAIMS BY }

THE APPLICANT OR OTHER MEMBER OF THE }

APPLICANT’S HOUSEHOLD IN THE PAST 5 YEARS }

WHETHER PAID OR NOT? }

IF YES,PROVIDEDETAILS

YES NO

DATE (YYYY/MM/DD)

HAS ANY INSURER CANCELLED, DECLINED, RESTRICTED, OR REFUSED TO RENEW ANY INSURANCE ON THIS PROPERTY? YES NO

IF “YES”, GIVE FULL DETAILS

NAME OF PREVIOUS INSURER

HOW MANY YEARS HAS THE APPLICANT HAD FARM INSURANCE WITH ANY INSURER?

IS THERE OTHER INSURANCE IN FORCE ON ANY OF THE PROPERTY DESCRIBED? YES NO

IF “YES”, POLICY # AND INSURER

WHERE (A) AN APPLICANT FOR THIS CONTRACT GIVES FALSE PARTICULARS TO THE PREJUDICE OF THE INSURER OR MISREPRESENTS OR FAILS TO DISCLOSE ANY FACT IN ANYPART 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 INSUREDMAKES A FALSE STATEMENT IN RESPECT OF A CLAIM, A CLAIM WILL BECOME INVALID AND THE INSURED’S RIGHT TO RECOVERY IS FORFEITED.

THE APPLICANTS HAVE REVIEWED ALL PARTS AND ATTACHMENTS OF THIS APPLICATION AND ACKNOWLEDGE THAT ALL INFORMATION IS TRUE AND CORRECT ANDUNDERSTAND THAT THIS APPLICATION FOR INSURANCE IS BASED ON THE TRUTH AND COMPLETENESS OF THIS INFORMATION.

I HAVE PROVIDED PERSONAL INFORMATION IN THIS DOCUMENT AND OTHERWISE AND I MAY IN THE FUTURE PROVIDE FURTHER PERSONAL INFORMATION. SOME OF THISPERSONAL INFORMATION MAY INCLUDE, BUT IS NOT LIMITED TO, MY CREDIT INFORMATION AND CLAIMS HISTORY. I AUTHORIZE MY BROKER OR INSURANCE COMPANY TOCOLLECT, USE AND DISCLOSE ANY OF THIS PERSONAL INFORMATION, SUBJECT TO THE LAW AND TO MY BROKER'S OR INSURANCE COMPANY'S POLICY REGARDING PERSONALINFORMATION, FOR THE PURPOSES OF COMMUNICATING WITH ME, ASSESSING MY APPLICATION FOR INSURANCE AND UNDERWRITING MY POLICIES, EVALUATING CLAIMS,DETECTING AND PREVENTING FRAUD, AND ANALYZING BUSINESS RESULTS. I CONFIRM THAT ALL INDIVIDUALS WHOSE PERSONAL INFORMATION IS CONTAINED IN THISDOCUMENT HAVE AUTHORIZED THAT I AGREE TO THE ABOVE ON THEIR BEHALF.

IS THIS BUSINESS NEW TO YOUR OFFICE? HOW LONG HAVE YOU KNOWN THE APPLICANT? HAVE YOU BOUND THE RISKS?

HAVE YOU SEEN THE PROPERTY? IF YES, WHEN (YYYY/MM/DD) CONDITION OF PROPERTY

ANY OTHER INSURANCE CARRIED WITH US? IF YES, POLICY NUMBERS

PHOTOS TAKEN? YES NO

YES NO YES NO

YES NO __________/_____/_____ GOOD FAIR POOR

YES NO ________________________________________________________________________________

REMARKS

SIGNATURE OF BROKER / AGENT DATE (YYYY/MM/DD)

SIGNATURE OF APPLICANT

�

SIGNATURE OF APPLICANT

�

DATE (YYYY/MM/DD)

�

DATE (YYYY/MM/DD)

�

POLICY NUMBER

EXPIRY DATE

YYYY/MM/DD

LOC. # CAUSE PAID AMOUNT ESTIMATED AMOUNT INSURANCE COMPANY POLICY NUMBER

CONSENT AND DISCLOSURE

BROKER / AGENT QUESTIONNAIRE


CSIO Farm Application

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