Irrigation Equipment Policy Application

Irrigation Equipment Policy Application

This application is specific to Center Pivots and should not be used to apply for any other insurance. Please contact our office with any questions
Coverage and Application Details
Replacement Cost
Stated Value
Application Date

MonthDayYear
Date
Effective Date

MonthDayYear
Date
Term
Total Equipment Value
Total Premium
Deductible - Pivot - $1,000
Deductible - Pivot - $2,500
Deductible - Pivot - $5,000
Deductible - Pivot - $10,000
Deductible - Ancillary - $1,000
Deductible - Ancillary - $2,500
Deductible - Ancillary - $5,000
Agency and Applicant Information
Agency Name
Agent Name

First NameMiddle NameLast Name
Applicant’s Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Loss Payee Information
Loss Payee Name
Loss Payee Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Loss Payee City
Loss Payee State
Loss Payee Zip Code
Schedules and Loss History
Equipment Schedules
Location Schedules
Prior Claims / Losses
Additional Comments
Signatures
Applicant's Signature
Applicant Signature Date

MonthDayYear
Date
Agent's Signature
Agent Signature Date

MonthDayYear
Date
Should be Empty: