Henry Equestrian Insurance Brokers
download printable version For manual submission, download this form here.
 

FARM INSURANCE QUESTIONNAIRE
TO BE COMPLETED AND SIGNED BY THE INSURED. ALL VALUES ARE SUBJECT TO REVIEW BY UNDERWRITING.
NAME OF OWNER(S)*:
STREET ADDRESS*:
CITY*:
POSTAL CODE*:
PROVINCE*:
BUSINESS PHONE NUMBER:
HOME PHONE NUMBER*:
FAX:
EMAIL ADDRESS *:
 
BUILDING A BUILDING B BUILDING C BUILDING D
Indicate building type:
Amount required: $ $ $ $
Deductible:
Occupancy:
Use:
Age:
Construction:
Roof Type:
Concrete Floor? yes no yes no yes no yes no
Dimensions of Building:
Heated? yes no yes no yes no yes no
    Type of Heat:
    Area Heated:
Produce? yes no
    Amount Required:
Jumps? yes no
    Amount Required:
    Where Kept:
Miscellaneous Tack and Equipment? yes no
    List total limit:
Any items over $3,500? yes no
    Description:
Livestock? yes no
    Number / Limit Per Horse:
Farm Equipment / Machinery? yes no
    Description / Age / Limit:
List all claims or potential claims in the last 6 years including dates, description of loss and, if possible, amount paid out by insurance company.
1. Date:
    Description:
2. Date:
    Description:
3. Date:
    Description:
4. Date:
    Description:
LIABILITY AMOUNT:

HOMEOWNER QUESTIONNAIRE MUST BE COMPLETED IN CONJUNCTION WITH THIS FORM

 
SIGNATURE (ENTER YOUR NAME)*: date signed
D M YEAR