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The Farmer Group, Inc.
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Personal Service, Total Protection
Phone
(502) 863-5300
Toll free
(888) 942-5361
Email
info@farmergroupinc.com
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Umbrella Liability Insurance Quote Request
CONTACT INFORMATION
Name
Address
City
State
Zip
Phone
Email
Best time to call
AM
PM
UNDERWRITING INFORMATION
Are any aircraft owned, leased, chartered or furnished for regular use?
Yes
No
Do any drivers have mental or physical impairments?
Yes
No
Are any premises, vehicles, watercraft, aircraft used for business?
Yes
No
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?
Yes
No
Do you engage in any type of farming operation?
Yes
No
Do you hold any non-remunerative positions?
Yes
No
Do you employ any residence employees?
Yes
No
Any non-owned property exceeding $1,000 in value in your care, custody or control?
Yes
No
Any non-owned business or professional activities included in the primary policies?
Yes
No
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
Yes
No
Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes
No
Any motorcycles, mopeds or all terrain vehicles owned?
Yes
No
Any other business activities conducted from your residence or premises?
Yes
No
Please explain any YES answers from above
200 character limit please
DRIVER INFORMATION
Driver 1 Info
ADD
HIDE
First Name
Last Name
Gender
Male
Female
Marital Status
Select
Single
Married
Divorced
Widowed
Separated
Years Licensed
License #
License Type
Driver 2 Info
ADD
HIDE
First Name
Last Name
Gender
Male
Female
Marital Status
Select
Single
Married
Divorced
Widowed
Separated
Years Licensed
License #
License Type
Driver 3 Info
ADD
HIDE
First Name
Last Name
Gender
Male
Female
Marital Status
Select
Single
Married
Divorced
Widowed
Separated
Years Licensed
License #
License Type
Driver 4 Info
ADD
HIDE
First Name
Last Name
Gender
Male
Female
Marital Status
Select
Single
Married
Divorced
Widowed
Separated
Years Licensed
License #
License Type
Violation Information
Last 3 years (minor violations), Last 5 years (major violations)
Driver 1
Driver 2
Driver 3
Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - non chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Major violations - drunk driving, reckless, hit and run, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Miscellaneous and Claims Information
Number of single family dwellings you own?
Number of autos you own?
Number of recreational vehicles you own?
Number of multi-unit buildings you own?
Number of vacant property (land) you own?
Number of motorcycles you own?
Where there any losses or claims in the last 5 years?
Yes
No
If yes, what is the date, amount paid and description of each loss or claim?
200 character limit please
Coverage Information
What is the current insurance company?
Select
20th Century
21st Century Casualty
AAA
AEGIS
AETNA
A G Edwards
AIG
Alliance
Allied
Allstate
American Family Insurance
American Manufacturers Mutual
American National General
Amica Mutual
Blue Cross
Calfarm
Charter Insurance
CIGNA
Civil Service Employees
Clarendon National
CNA
Colonial Penn
Company Not Listed
Continental
Country Companies
Dairyland
Don't know name
Electric
Farm Bureau Insurance
Farmers
Farmers Union
Fidelity Guaranty
Fireman's Fund
First General
GEICO Casualty Co.
General Accident
Grange Ins Assn
Guaranty National
Hanover
Hartford
Horace Mann
John Hancock
Kemper
Liberty Mutual
Lumbermans Mutual
Metropolitan Insurance
Midwest Security
Millers Mutual Fire
Mutual of Omaha
Mutual of New York
National Farm Bureau
National General
Nationwide
New York Life
Northwestern Pacific
Pennsylvania General
Progressive
Providian
Prudential
Rural Insurance
SAFECO
Sentry
Shelter
State Farm
Travelers
Unigard
USAA
Viking
Workmens
Company Not Listed
Don't know name
How much are you paying now?
What is the liability limit requested?
Select
$100,000
$300,000
$500,000
$1,000,000
Questions or Comments:
200 character limit please
Please Note: We cannot bind coverage from this email. Coverage is bound after you receive an email or telephone call from one of our agency staff members.
Please fill out the form below and submit via secure server to Farmer Group, Inc.. You will be contacted by one of our friendly representatives shortly. You may also call our office at 888-942-5361 at any time for assistance with your quote.
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