On-line Farm Insurance


Thank you for considering our on-line farm insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right farm insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deal that fits your requirements.

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

1. Domestic Buildings and Contents
2. Farm Property
3. Tractors & Farm Machinery
4. Livestock & Working Dogs
5. Machinery Breakdown
6. Farm Liability
7. Business Interruption
8. Personal Accident and Illness
9. Transit
10. General Details
11. Contact Details
12. Submit Form
1. Domestic Buildings and Contents
What type of cover do you require?
Insured Events Cover Defined events (e.g. fire, storm or rainwater, theft, earthquake etc.) damage to home and to contents anywhere on the farm.
Accident 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
  square metres or
  square metres or
 squares (10' x 10')  squares (10' x 10')  squares (10' x 10')
Construction Materials -
Walls:
Roof:
Sum Insured -
Home ($):
Contents ($):
Have any Security Devices been installed? tick if yes tick if yes tick if yes
Deadlocks(all doors):
Key locks (all windows):
Alarms:
Smoke Detectors:
Other (give details):
Special Contents (Items - worth over $20,000)
Item:
Value $
Item
Value $
Are there any further details relating to Domestic Buildings and Contents you wish to provide?
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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
$
$
$
$
Are 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
Are there 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
$
$
$
$
Are there 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 Selected Machinery Cover
5a. Blanket Cover - Fill in the following table:
Dairies with 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
5b. Selected Machinery Cover - Specified Items (Machinery Cover and Pressure Vessels - when Blanket cover not taken):
Description Sum Insured
$
$
$
$
$
$
Deterioration of Refrigerated Goods (only if a) selected or machinery listed at b): Sum Insured: $
Are there any further details relating to Machinery Breakdown you wish to provide?
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6. Farm 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):
Are there any further details relating to Farm Liability you wish to provide?
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7. Business Interruption
Agistment Income: $
Farming Continuation Expenses: $
Are there 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.
1. Has this person ever been insured against injury or illness, now or before?
First Person Second Person
Yes No
Yes No
2. Do you currently, or do you intend to engage in any hazardous pursuits or pastime including but not limited to motor sports in any form; 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 such an insurance 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 tumor 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 or have you taken prescribed medication of any kind? (It is not necessary to answer "Yes" if only for colds and flu)
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 recurrence 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
Are there any further details relating to Personal Accident and Illness you wish to provide?
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9. Transit
This section provides cover for Livestock, Farm produce, General Farm Goods and Farm Machinery
Sum Insured
$
Are there 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. Mortgagers or Lessors)
Names and Addresses:
Address(es) of property to be insured:
If you answer Yes to any of the following questions, please provide full details including name of insurer, dates, amount in $'s, reason for cancellation:
a) 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
b) Have you or any partner(s), shareholder(s) or director(s) of the business
1. ever been declared bankrupt?
Yes No
2. ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. liquidation or receivership)?
Yes No
3. been convicted of any criminal offence within the past 5 years (other than minor traffic infringements)?
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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11. Contact Details


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:

My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: