Farm Insurance

Name:
Phone:
Email:
Address:
Suburb:
Post code:
Location:
Mortgagee:
Hectares:
Farm Type:

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Duty of Disclosure

Have you ever...

Had any convictions/DUI?	NoYes	If Yes, details:
Over the past 5 years have you had any claims?	NoYes	If Yes, details:
Have you had Insurance Declined?	NoYes
What is the current Insurance Due Date?	(enter as DD/MM/YYYY)

Please select yes or no to each section:

Section 1 - Home: No Yes

Section 2 - Farm Property: No Yes

Section 3 - Farm Machinery: No Yes

Section 4 - Theft: No Yes

Section 5 - Hay, Fencing, Livestock: No Yes

Section 6 - Business Interruption: No Yes

Section 7 - Liability: No Yes

Section 8 - Machinery Breakdown: No Yes

Section 9 - Personal Income: No Yes

Section 10 - Road Transit: No Yes

Section 11 - Motor Insurance: No Yes

Section 12 - Other Insurance:

Please explain what other types of insurance you require

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