Irrigation Equipment Insurance Application

Are you a Broker filling out this form on behalf of a customer?*
- Yes
- No
Agency Name*
Agency Contact*
First Last
Phone*
Email*
Applicant Name*
Applicant Contact info*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Proposed effective date*
Date Format: MM slash DD slash YYYY
Total Equipment Value*
Any prior losses in past five years?*
- Yes
- No
Please attach loss runs and provide description of loss including date and payout*
Click the plus to the right to create additional entries
Loss Date Total Amount of Loss Description
Upload Loss Runs
Drop files here or
Current Insurance Carrier*
Desired Deductible*
- $1,000
- $2,000
Equipment Schedule
Click the plus to the right to create additional entries. If you have a schedule that contains all of the information needed below, click below to upload file.
Year Make Model & Description (Tower count and length can be included) Serial # Value RV or ACV?
Upload Equipment Schedule

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Loss Date	Total Amount of Loss	Description

Year	Make	Model & Description (Tower count and length can be included)	Serial #	Value	RV or ACV?