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

Agency Phone Number*

Agency Email Address*

Applicant Name*

Applicant Contact info*

First Last

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address*

Same as previous

Street Address Address Line 2 City State ZIP Code

Applicant Phone Number*

Applicant Email Address*

Proposed effective date*

Total Equipment Value*

Desired Per Occurence Deductible

Any prior losses in past five years?*

Yes
No

Current Insurance Carrier*

Please provide description of loss including date and payout.*

Click the plus to the right to create additional entries. If you have loss runs that contains all of the information needed below, click below to upload file.

Loss Date	Total Amount of Loss	Description

Upload Loss Runs

Drop files here or

Max. file size: 50 MB.

Location 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.

State	Quarter Section/ Farm Name	Township	Range	County	Zip Code of Pivot

Upload Location Schedule

Max. file size: 50 MB.

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 must be included)	Serial #	Value ($13,000 minimum value)

Upload Equipment Schedule

Max. file size: 50 MB.