MASTER FARM QUESTIONNAIRE
PLEASE PRINT THIS QUESTIONNAIRE, COMPLETE,  MAIL or FAX TO:
Midwest Insurance Consultants, Ltd.
Box 58
Nevada, IA 50201
Phone: 1-800-729-4341
FAX: 1-515-382-3844

Farm Management Firm: _________________________________________
Address: _________________________________________
City: ____________________  State_____  Zip_______
Contact Name: _________________________________________
Phone: _________________________________________
Fax: _________________________________________
E-mail: _________________________________________
Approximate Number of Farms Managed: _______
Approximate Number of Acres: _______
States Where Farms are Located: _________________________________
_________________________________
_________________________________
How are Farms Currently Insured?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What Policy Date Would You Like? _________________________________

(An agent in the agribusiness department will review your questionnaire and will contact you by phone for additional information needed for quote).

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