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Farm and Ranch Insurance Quote Form

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  
Your occupation:  
Date of Birth:  

Current Insurance Information
Insurance Company Name:  
Policy Exp. Date:  
Amount Insured for:  
Mortgage Amt:  
Premium Amt:  
Term:  
Location of Farm:  
Name of Farm:  
Type of Farm:  
# of Acres:  
# of employees:  

Values of ($):  
Home
Building / Barn #1
Building / Barn #2
Building / Barn #3
Building / Barn #4
Farm Equipment
Crops
Animals

Level of Liability:  

Describe losses in last 5 years:  
Please give any additional information that did not have enough room for that may assist us in your farm quote:



106 S. Penn
Oberlin, Ks 67749
Tel: (785) 475-3310
Fax: (785) 475-8965
117 N. Kansas
Norton, KS 67654
Toll Free: 866-484-6236
Tel: 785-877-4016
Fax: 785-874-4832
PO Box 235
101 Front St.
Winona, KS 67764
Tel: (785) 846-7476
Fax: (785) 846-7479