Personal/Farm Umbrella Questionnaire
Name:
First Name
Last Name
Effective Date:
-
Month
-
Day
Year
Date
Do you own a jet ski?
Yes
No
If yes, what is the horsepower?
How many passengers does it seat?
Is there a swimming pool located on the premises?
Yes
No
If yes, is the pool in-ground or above ground?
In-Ground
Above Ground
If yes, is it fenced with a lockable gate?
Yes
No
Is the pool equipped with a diving board or a slide?
Yes
No
Is the pool equipped with a diving board or a slide?
Yes
No
Is there a trampoline on the premises?
Yes
No
Is there a skateboard ramp on the premises?
Yes
No
Do you have any drivers under the age of 25 in the household that is not currentlylisted on your policy?
Yes
No
If yes, please list the name, date of birth, and driver’s license number?
For rental property: What are the Gross Annual Receipts for each property?
If your policy is a Farm Umbrella please complete the additional information below:
Do you own any horses?
Yes
No
If yes, how many?
Do you farm (crops) or ranch (livestock)?
If you custom farm, what are the gross annual receipts?
Do you hire farm employees?
Yes
No
If yes, how many?
Signature
Submit
Should be Empty: