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 Brokers National 

Brokers National can assist farmers & those with hobby farms with a comprehensive Rural / Farm insurance package                                               The Rural / Farm policy includes cover for both the Farm, & also your Home, Household Contents, Motor Vehicles, Personal Liability, & other personal assets                                             Farm equipment, farm buildings, & farm liability can also be insured under the one policy                                    Simply answer all questions below          

EMAIL Or Fax

On-Line Farm Quote


 Thank you for considering our on-line farm insurance quote service. Brokers National has accounts with most insurers and underwriting agencies. We aim to find you the farm insurance deal possible.

Please fill in the following form - answering all questions, then either:

1. Click on "Email to Brokers National" at the bottom of this form.  OR                               

2. Highlight this form to "Print It" and then "Fax It" to our office on 03 9791 6633.


 Use the Mouse or the Tab key to move to the next field. We will respond with quotes as soon as they have been received from our insurers.

Note: Use the links below to go to different sections of this quote form:

Select 1
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   Domestic Buildings and Contents
Farm Property
Tractors & Farm Machinery
Livestock & Working Dogs
Machinery Breakdown
Farm Liability
Business Interruption
Personal Accident and Illness
Transit
General Details
Contact Details
Submit Form
 

1. Domestic Buildings and Contents

Select type of cover? Insured Events Cover or
- Defined events (e.g. fire, storm or rainwater, theft, earthquake etc.) damage to home and to contents anywhere on the farm.
Accidental Damage Cover
- Accidental loss or damage to home and to contents anywhere in Australia

 
Building 1
Building 2
Building 3
Description:
(e.g. cottage) 
 
Main Homestead
Postcode:
 
Who occupies the house?
 
Year Built:
 
Size:
 
square metres or
squares (10' x10')
square metres or
squares (10' x 10')
square metres or
squares (10' x 10')
Construction - Walls:
 
Roof:
 

Sum Insured - Home:

 $
Contents:
$
Security Installed?
Deadlocks(all doors):
 
tick if yes:
tick if yes:
tick if yes:
Keylocks (all windows):
 
Alarm:
 
Smoke Detectors:
 
Other (give details):
 
Special Contents
(Any Items - over $20,000)
 $
Item 1:
Item 2:
 
Item 3:
Are there any other details to advise for any Domestic Buildings and Contents?
 

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2. Farm Property

Farm Buildings:
Description
Construction
Age
(years)
Replacement?
(Tick for yes)
Sum Insured
$
$
$
$
$
$
$
$
$

 

Fencing: Boundary not shared

  $

               -Boundary shared

  $

               -Sub-divisional

  $

               -All fencing

  $
Farm Contents:
 

$
Farm Consumables:
  $
 
Hay:
  $
 
Above ground farm improvements:
(e.g. water/fuel tanks, silos, bore pumps, power lines etc...)
  $

Specified Items (Including Electronic Equipment)       Item Description:

  Sum Insured
$
$
$
$
Is there any further details relating to Farm Property you wish to provide?
 

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3. Tractors and Farm Machinery

Year Make & Model or Description Engine or Serial Number Sum Insured
$ 
$
$ 
$ 
$ 
$ 
$ 
Any further details relating to Tractors and Farm Machinery you wish to provide?
 

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4. Livestock & Working Dogs

Livestock - Type of Animal
Sum Insured
$
$
$
$
$
Working Dogs- Description:
  Sum Insured
$
$

Any further details relating to Livestock and Working Dogs you wish to provide?

  

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5. Machinery Breakdown

Please choose either Blanket Cover or Listed Machinery Cover

a) Blanket Cover - Fill in the following table:

Dairies- Vat capacity up to:
 Sheep Stations Up to 10,000 head
5 000 litres
Cattle Up to 1,000 head
10 000 litres
Pastoralists
15 000 litres
Piggeries
35 000 litres
Poultry Layers

b) Selected Machinery Cover - Specified Items (Machinery Cover and Pressure Vessels - when Blanket cover not taken):

Description
  Sum Insured
$
$
$
$
$
$
Deterioration of Refrigerated Goods Sum Insured:
$

Any further details relating to Machinery Breakdown you wish to provide?

  

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6. Farm Public Liability

Liability Limit of Indemnity:
$
Number of working proprietors:
 
Number of employees:
 

Is your property used or leased for any purpose other than primary production
(e.g. sand and gravel pits or any other non-farming activity)? If yes state details of activity:

Do you derive any income from contract farming?
If yes, what percentage of your business income is involved? %
State details (if yes):

Any further details relating to Farm Liability you wish to provide?

  

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7. Business Interruption

Agistment Income:
$
Farming Continuation Expenses:
$

Any further details relating to Business Interruption you wish to provide?

  

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8. Personal Accident and Illness

    First Person Second Person
Surname:
 
First/Second Name:
 
Date of Birth (DD/MM/YYYY):
 
Height & Weight:
  cm   kg cm   kg
Cover Required:
 

Accident and Illness or
Accident Only

 Accident and Illness or
Accident Only
Benefits required:
  Capital Sum  $ 
Weekly Sum $  		Capital Sum  $ 
Weekly Sum $ 

For the following questions, if you answer yes to any question (Insurance or Medical) please give details including description of injury or illness, duration (dates), the cause, nature of treatment and results, current condition, name and addresses of doctors and hospitals consulted.

    First Person Second Person
1. Has this person ever been insured against injury or illness?
  Yes No
Yes No
2. Do you engage in any hazardous pursuits or pastime including motor sports, rock climbing; water skiing; snow skiing; horse riding?
  Yes No
Yes No
3. Is this person engaged in work other than farming, with you or elsewhere?
  Yes No
Yes No
4. Have special terms ever been imposed for life or disability insurance or has any person ever been declined?
  Yes No
Yes No
5. Has this person received medical advice, consulted a doctor, undergone any medical treatment or investigations for high blood pressure or cholesterol; any heart complaint or problem; HIV. AIDS or AIDS related conditions; stroke; kidney, bowel, bladder or liver disease; cancer or tumour of any type; diabetes; asthma or any lung complaint; mental, nervous or depressive disorder; epilepsy; alcohol or drug abuse; nervous system disorder?
  Yes No
Yes No
6. During the last 5 years, has this person suffered from any other health problem or physical impairment not mentioned above? 
  Yes No
Yes No
7. Does this person currently have any symptoms of ill health or injury? Are you taking prescribed medication of any kind?   Yes No
Yes No
8. Is there any likelihood of re-occurrence of any illness or injury previously suffered or the possibility of this person undergoing surgery or other treatment?   Yes No
Yes No
9. Do you receive any income or reward for playing sport? (Professional sporting activities are not insured)   Yes No
Yes No

Any further details relating to Personal Accident and Illness you wish to provide?

  

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9. Transit

  Sum Insured
This section provides cover for Livestock, Farm produce, General Farm Goods and Farm Machinery
$

Any further details relating to Transit you wish to provide?

  

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10. General Details

Name(s) in full:
(Include all individual and trading names)
Property Details: Name(s):
Type of farm:
if "Other" please describe:
Other interested persons (e.g. Mortgagees or Lessors)
Names and Addresses:
Situation(s) of property to be insured:

If you answer Yes below, please provide full details:

Have you in the past 5 years:
1. Made any claim(s) on an insurer for loss or damage?		   Yes No
2. Had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, or special conditions or non-standard excess imposed by an insurer?   Yes No
3. Suffered any loss or damage which would have been covered by the proposed insurance policy?   Yes No
Have you or any partner(s), shareholder(s) or director(s):
1. Ever been declared bankrupt?		   Yes No
2. Ever been involved in a company or business which became insolvent or subject to administration?   Yes No
3. Been convicted of any criminal offence within the past 5 years?   Yes No
4. Been liable for any civil offence or pecuniary penalty (exceeding $5000)?   Yes No

If you would like to provide extra general details please do so in the box provided:

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Contacting you about your quote:

Please make sure you leave a contact phone number and the best time to call you.
Your Name:
Company name:
Your Phone Number & Area Code:
Best Time(s) To Call:
Please send my quote by (select at least one): email     phone     fax     mail
Your Email:
Your Facsimile:
Your Postal Address:

Click On Email Quote To Send         Form To Us
 

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