Farm Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client to RIB?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
Date
Interested Party
Contact Number
Email Address
example@example.com
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Details
Full Details of Farming Operations
No. of Employees
Size of Property
Estimated Turnover
Claims History
For last 5 years
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #3
Amount
Risk Details
Situation of Risk
Rows
Not Satisfied
Situation of Risk #1
Situation of Risk #2
Situation of Risk #3
Domestic Building & Contents Section
Situation #1 Details
Farm Size (acres/hectares)
Building Type
Please Select
House
Unit
Flat
Holday/Weekender
Age of Building
No. of Floors
Rewired (if applicable)
Please Select
Yes
No
Replumbed (if applicable)
Please Select
Yes
No
Wall Construction
Roof Construction
Floor Construction
Occupancy
Please Select
Owner
Tenant
Cover
Please Select
Defined Events
Accidental Cover
Sums Insured- Buildings
Sums Insured- Contents
Flood Cover
Please Select
Yes
No
Retired
Please Select
Yes
No
Security
Please Select
Window Locks
Deadlocks
Alarm - Local
Alarm- Monitored
Other
Connected to Town Water
Please Select
Yes
No
Excess
Please Select
100
250
500
1000
Other
Valuables
$
Specified Contents
$
Year Built
Property Section
Building
Rows
Situation No.
Construction
Year Built
Sum Insured $
Cover
Building #1
Replacement
Indemnity
Building #2
Replacement
Indemnity
Building #3
Replacement
Indemnity
Building #4
Replacement
Indemnity
Building #5
Replacement
Indemnity
Unspecified Farm Buildings
Farm Contents (fire)
Rows
Sum Insured
Cover
Situation #1
Replacement
Indemnity
SItuation #2
Replacement
Indemnity
Situation #3
Replacement
Indemnity
Situation #4
Replacement
Indemnity
Situation #5
Replacement
Indemnity
Farm Machinery and Working Dogs Section
Rows
$
Situation Number
1
#1
#2
#3
#4
#5
2
#1
#2
#3
#4
#5
3
#1
#2
#3
#4
#5
4
#1
#2
#3
#4
#5
5
#1
#2
#3
#4
#5
Unspecified Farm Machinery – limit $2,500 any one item
#1
#2
#3
#4
#5
Unspecified Farm Machinery – limit $2,500 any one item
#1
#2
#3
#4
#5
Unspecified Farm Machinery – limit $2,500 any one item
#1
#2
#3
#4
#5
Working Dogs
#1
#2
#3
#4
#5
Theft Section
Rows
$
Situation Number
Farm Contents
#1
#2
#3
#4
#5
Farm Contents
#1
#2
#3
#4
#5
Farm Contents
#1
#2
#3
#4
#5
Specified Farm Machinery
#1
#2
#3
#4
#5
1
#1
#2
#3
#4
#5
2
#1
#2
#3
#4
#5
3
#1
#2
#3
#4
#5
Hay, Fencing & Livestock Section
Rows
$
Situation Number
Hay
#1
#2
#3
#4
#5
Hay
#1
#2
#3
#4
#5
Hay
#1
#2
#3
#4
#5
Livestock Type
#1
#2
#3
#4
#5
Livestock Type
#1
#2
#3
#4
#5
Livestock Type
#1
#2
#3
#4
#5
Livestock Type
#1
#2
#3
#4
#5
Fencing: Boundary not shared
#1
#2
#3
#4
#5
Fencing: Boundary shared
#1
#2
#3
#4
#5
Fencing: All fencing
#1
#2
#3
#4
#5
Fencing: Boundary not shared
#1
#2
#3
#4
#5
Fencing: Boundary shared
#1
#2
#3
#4
#5
Fencing: All fencing
#1
#2
#3
#4
#5
Business Interruption Section
Rows
$
Situation Number
Income
#1
#2
#3
#4
#5
Farming Continuation Expenses
#1
#2
#3
#4
#5
Other
#1
#2
#3
#4
#5
Income
#1
#2
#3
#4
#5
Farming Continuation Expenses
#1
#2
#3
#4
#5
Other
#1
#2
#3
#4
#5
Indemnity Period #1
Indemnity Period #2
Broadform Public/Products Liability Section
Limit of Indemnity
Public Liability
$
Products Liability
$
Do you require cover for aircraft landing areas?
Please Select
Yes
No
Is your property used or leased for any purpose other than farming?
Please Select
Yes
No
Do you derive any income from contract farming?
Please Select
Yes
No
If you answered yes to any of the above questions please advise details:
Machinery Breakdown Section
Rows
$
Situation Number
Limit Per Event
#1
#2
#3
#4
#5
Limit Per Event
#1
#2
#3
#4
#5
Limit Per Event
#1
#2
#3
#4
#5
Machinery Breakdown Section
Rows
Number of Units
Description of Units
$
Situation Number
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
Rows
Deterioration of Stock
Description
$
Situation Number
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
-
#1
#2
#3
#4
#5
Personal Income Section
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Height
Weight
Occupation
Questionnaire: Has the person to be Insured suffered from:
Rows
Yes
No
1. Any injury to, or illness or disease of, your
a) Heart, lungs, blood vessels or circulatory system?
b) Bones, joints, muscles, limbs or skin?
c) Head, back, neck or spine?
d) Kidney, urinary tract or reproductive organs?
e) Brain, nervous system or auto – immune system?
f) Stomach, bowel or digestive system?
g) Eyes, ears, nose or throat (other than infrequent colds)?
2. A hernia?
3. Any infectious disease or viral infection (other than infrequent colds)
4. Any mental illness or disease, or stress related condition?
5. Any other injury, illness or disease?
If “Yes” please provide full details:
Are you intending to ever engage in any hazardous activity?Eg. Football, rock climbing, motorcycling, motor sport, snow skiing etc.
Yes
No
If “Yes” please provide full details:
Capital Benefit
$
Weekly Accident Benefit
$
Weekly Illness Benefit
$
No. of weeks (standard over 104 weeks)
Road Transit Section
Livestock
$
General Farm Goods
$
Farm Produce
$
Farm Machinery
$
Motor Vehicles Section
Please note documentary proof of no claim bonus is mandatory and must accompany this document
Rows
Year of Make
Vehicle Details
Rego No.
Year of Birth of Driver
Sum Insured $
Type of Cover
-
Comp
FT & TP
TP
-
Comp
FT & TP
TP
-
Comp
FT & TP
TP
-
Comp
FT & TP
TP
-
Comp
FT & TP
TP
Do you wish to remove the excess?
Please Select
Yes
No
Do you require windscreen extension?
Please Select
Yes
No
Limit of liability required for third party property damage:
Please Select
$5 million
$10 million
$15 million
$20 million
Driver Details
Rows
Name of Driver
Date of Birth
Details of Vehicles Driven
-
-
-
-
Proposers and other Drivers Questionnaire
Rows
Yes
No
Will any drivers under 25 years of age be driving the vehicle?
If yes, do these drivers own their own vehicles?
Does the vehicle have any existing damage, defects (rust, hail or unrepaired body damage)?
Does the vehicle have any mechanical or other problems which will make it unsafe?
Do any of the drivers (who drive more than 10% of the time) have less than 2 years driving experience?
Is the vehicle fitted with a security device? (e.g. alarm system, engine mobiliser, tracking system)
Standard
After factory fitted
Has the insured or any drivers ever been declared bankrupt or been placed in receivership?
Has the Insured or any drivers ever had insurance cancelled, declined or special conditions imposed?
Has the Insured or any drivers ever been charged or convicted of any criminal offence including drug use, driving under the influence or any driving offence, speeding infringements, fraud, arson or theft?
Does the Insured or drivers suffer from any physical or mental disability (excl. eyesight corrected by lens)?
If Yes, Provide Full Details
Broker Recommendations
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