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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:
Note: By submitting this form you understand that no coverage is bound until you receive written notice.
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1 S. Ohio Avenue, Wellston, Ohio 45692  |  Toll Free: 800-759-5364    Tel: 740-384-2020  Email to: peggy@lockardinsuranceinc.com
Copyright © 2006. Lockard Insurance Agency, Inc.. All Rights Reserved.  We are licensed in the State of Ohio.