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