Home Office: One Nationwide Columbus, Ohio 43215 • Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 • 1-800-423-7675 Fax (480) 483-6752 • www.scottsdaleins.com FARM AND RANCH APPLICATION Date: Agency Name/Address: Applicant’s Name: Phone: Fax: Mailing Address: E-mail: City: ST: County: Code: Subcode: Phone No.: Bus. No.: Agency Customer ID: Effective Date: Expiration Date: E-mail: Web Site Address: APPLICANT INFORMATION Previous Address Years at Previous Address: Location of property if different from above: (if less than three years) Street: Street: City: ST: City: ST: County: Applicant’s Occupation Marital Status DOB Applicant’s Employer Name and Address: (State nature of business if self-employed): Co-Applicant’s Occupation Marital Status DOB Co-Applicant’s Employer Name and Address: nature of business if self-employed): COVERAGES/LIMITS OF INSURANCE—PRIMARY LOCATION (Complete Additional Farm Dwelling Supplemental Application for additional locations) Bodily Injury Other Private Personal Barns & Farm Location 1 Dwelling Loss of Use and Property Medical Payments Structures Property Personal Property Building 1 (Coverage A) (Coverage D) Damage (Coverage J) (Coverage B) (Coverage C) (Coverage E&G) (Coverage H) Complete Limit $ $ $ $ Supplemental $ $ Application Broad Broad Basic Broad Cause Of Loss Special Special Loss ACV RC Same as ACV RC Settlement FRC Coverage A Deductible Type & Amount (%/$) All Wind & Hail: Other: RATING/UNDERWRITING—PRIMARY LOCATION Year Built Purchase Date Construction Type Usage Type Occupancy Windstorm Loss Mitigation Features Frame Modular Home Primary Owner Hurricane Straps Masonry EIFS Secondary Tenant Wind Shutters Masonry Veneer Log Home Seasonal Farm Renter HIP Roof Square Feet Replacement (Tenant Package) Joisted Masonry Hand-hewn COC/Reno Impact Resistant Glass Cost Vacant Fire Resistive Milled $ No. of MFG/Mobile Home Kit Months: No. Families Market Tied Down $ Portable Skirted Territory Protection Distance To Protection Device Type Visible to Neighbors: Yes No Code Class Hydrant Fire Station System Smoke Temperature Burglar Foundation: Open Closed Stilts FT MI Central Sprinklers: Full Partial Fire District / Code No.: / Local Partial Complete Year Details Updates
Home Office: One Nationwide • Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive • Scottsdale, Arizona 85258 1-800-423-7675 • Fax (480) 483-6752 www.scottsdaleins.com FARM AND RANCH APPLICATION Date: Agency Name/Address: Phone: Fax: E-mail: Applicant’s Name: Mailing Address: City: ST: County: Code: Subcode: Phone No.: Bus. No.: Agency Customer ID: Effective Date: Expiration Date: E-mail: Web Site Address: APPLICANT INFORMATION Previous Address (if less than three years) Years at Previous Address: Street: City: ST: Location of property if different from above: Street: City: ST: County: Applicant’s Occupation (State nature of business if self-employed): Marital Status DOB Applicant’s Employer Name and Address: Co-Applicant’s Occupation nature of business if self-employed): Marital Status DOB Co-Applicant’s Employer Name and Address: COVERAGES/LIMITS OF INSURANCE—PRIMARY LOCATION (Complete Additional Farm Dwelling Supplemental Application for additional locations) Location 1 Building 1 Dwelling (Coverage A) Other Private Structures (Coverage B) Personal Property (Coverage C) Loss of Use (Coverage D) Barns & Farm Personal Property (Coverage E&G) Bodily Injury and Property Damage (Coverage H) Medical Payments (Coverage J) Limit $ $ $ $ Complete Supplemental Application $ $ Cause Of Loss Broad Special Broad Special Basic Broad Loss Settlement ACV RC FRC Same as Coverage A ACV RC Deductible Type & Amount (%/$) All Wind & Hail: Other: RATING/UNDERWRITING—PRIMARY LOCATION Year Built Purchase Date Construction Type Frame Modular Home Masonry EIFS Masonry Veneer Log Home Joisted Masonry Hand-hewn Fire Resistive Milled MFG/Mobile Home Kit Tied Down Portable Skirted Usage Type Primary Secondary Seasonal COC/Reno Occupancy Owner Tenant Farm Renter (Tenant Package) Vacant No. of Months: Windstorm Loss Mitigation Features Hurricane Straps Wind Shutters HIP Roof Impact Resistant Glass Square Feet Replacement Cost $ No. Families Market $ Territory Code Protection Class Distance To Protection Device Type Visible to Neighbors: Yes No Hydrant Fire Station System Smoke Temperature Burglar Foundation: Open Closed Stilts FT MI Central Sprinklers: Full Partial Fire District / Code No.: / Local Updates Partial Complete Year Details
SIC-Farm-and-Ranch.docx