Custom Applicator Application Form

Our Policy is to Serve You

Custom Applicator Application Form

Business Name

Primary Owners Name

Email Address

1. How many acres do you expect to Custom Spray this year?

How many acres did you Custom Spray last year?

How many acres do you expect to Custom Float this year?

How many acres did you Custom Float last year?

2. How many sprayers will you be using this season?

How many floaters will you be using this season?

3. Do all operators have a minimum of 2 years of custom application experience using similar equipment?

If no, please explain

4. Do you have any other operations to insure under this policy (ie. Snow Clearing, Custom Harvesting, Trucking, Soil Testing, NH3 Application, Other)?

5. Have you purchased any new equipment that you would like insurance coverage for?

If yes, please provide us with the year, make, model, serial number, value & lienholder name

Liendholder mailing address:

Was this a trade-in?

If yes, please provide us with the year, make, model and serial number of the unit that is to be removed

Please provide the effective date that the above unit(s) are the be added/deleted from the policy:

6. In the past 12 months, have there been any situations or incidents that may result in a claim? If yes, please provide details:

Custom Applicator Application Form

Custom Applicator Application Form

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