SMALL BUSINESS SOLUTIONS
Telephone: 1-800-233-9713
Facsimile:1-866-229-3303
Small Business Solutions
Farm Questionnaire (not Ontario)
(Please complete and return by fax or call us with the information)
BROKER NAME:
DATE:
INSURED’S NAME:
POLICY NO.:
Describe the type of farming operation:
Reside on the farm: Yes
No
% of income from farming:
List All Vehicles in the Household
Veh. No.
Use (including nonfarm rated vehicles
Percentage of
Radius
Annual
Km
Off Farm Use
Destination
If attached equipment, provide:
Vehicle No. & description of attached equipment:
List price new:
CGL Carrier:
Any delivery of goods to farmer’s market? Yes
Transport livestock? Yes
No
Max. capacity of the livestock trailer?
Policy # :
No
Expiry Date:
Frequency:
Own livestock? Yes
No
Livestock of others? Yes
No
No. of livestock transported any one time:
Maximum no. of trips/month:
RSA is a registered trade name of Royal & Sun Alliance Insurance Company of Canada. "RSA" and the RSA logo are trademarks used under license from RSA Insurance Group plc.
32035 (12/2004)
P. 1 of 2
SMALL BUSINESS SOLUTIONS
Telephone: 1-800-233-9713
Facsimile:1-866-229-3303
Small Business Solutions
Farm Questionnaire (not Ontario)
(Please complete and return by fax or call us with the information)
Do you own trailers?
Yes
No
Do you use non-owned trailers: Yes
Any US exposure?
Yes
No
No
Destinations:
If hauling done for others, please specify:
Materials hauled:
Radius
Any change in listed drivers since last renewal? Yes
Frequency:
No
If yes, provide updated driver list.
Do you employ seasonal workers?
Yes
No
Do they have regular use of vehicles?
Yes
No
If yes, please comment on any driver control procedures in place (e.g. age restrictions, hours of operation, etc.).
Supporting personal auto insurance with R&SA/affiliated partners? Yes
No
Policy No.:
Comments:
32035 (12/2004)
P. 2 of 2