Brokerage/Authorised Representative Details

Brokerage/Authorised Representative Your Email Address Your Phone Number

To receive a quote from ARGIS, please complete all required sections prior to submitting the quote request. You are able to switch between pages of the form without losing data, however you will not be able to save incomplete forms. At the end of the quote process a copy of the quote request form will be generated to the email you've entered.

Section 1 - Insurer Details

Insured Name Current Insurer Due Date

Number of Situations 1 2 3 4 5 Situation Address 1 Postcode

Farm Size (in Hectares) HA Farm Type 0111A - Nursery Production (Under Cover) 0112A - Nursery Production (Outdoors) 0113B - Turf Growing 0114A - Floriculture Production (Under Cover) 0115A - Floriculture Production (Outdoors) 0121A - Mushroom Growing 0122A - Vegetable Growing (Under Cover) 0123A - Vegetable Growing (Outdoors) 0131A - Grape Growing 0132A - Kiwifruit Growing 0133A - Berry Fruit Growing 0134A - Apple & Pear Growing 0135A - Stone Fruit Growing 0136A - Citrus Fruit Growing 0137A - Olive Growing 0139A - Other Fruit & Tree Nut Growing 0141A - Sheep Farming (Specialised) 0142A - Beef Cattle Farming (Specialised) 0144A - Sheep-Beef Cattle Farming 0145A - Grain-Sheep or Grain-Beef Cattle Farming 0146A - Rice Growing 0149A - Other Grain Growing 0151A - Sugar Cane Growing 0152B - Cotton Growing 0159C - Other Crop Growing n.e.c. 0160A - Dairy Cattle Farming 0193A - Beekeeping 0143A - Beef Cattle Feedlots (Specialised) 0150A - Hobby Farm 0171A - Poultry Farming (Meat) 0172A - Poultry Farming (Eggs) 0180A - Deer Farming 0191A - Horse Farming 0192A - Pig Farming 0199A - Other Livestock Farming n.e.c. 0201A - Offshore Longline & Rack Aquaculture 0202A - Offshore Caged Aquaculture 0203A - Onshore Aquaculture Additional Details of Occupation

Please tick if you derive any income from activities other than own farming

Additional Notes

Please tick if cover required for Farm Buildings

Please tick if cover required for Farm Contents

Please tick if cover required for Farm Contents Theft

Please tick if cover required for Machinery Breakdown

Please tick if cover required for Fire: Fencing, Farm Machinery & Sundry Items

Please tick if cover required for Fire: Livestock

Please tick if cover required for Farm Working Dogs

Please tick if cover required for Livestock

Please tick if cover required for Farmers Liability

Please tick if cover required for Dwelling and Contents of Dwelling

Please tick if cover required for Personal Effects

Please tick if cover required for Private, Farm & Business Vehicles

Please tick if cover required for Personal Accident and Sickness

Please tick if cover required for Pleasure Boat

Please Complete the Following Questions for All Sections 1. Has the insured in the past five years: a) Had any insurance declined or cancelled, proposal rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer? YesNo b) Suffered any loss or damage whether you made an insurance claim or not, or had any claims made against you? YesNo If YES, full details (e.g., name of insurer, dates, type of loss or damage, amount) 2 Has the insured: a) Ever been declared bankrupt? YesNo b) Ever been involved in a company or business which has become insolvent or subject to any form of insolvency administration (e.g. liquidation or receivership)? YesNo c) Been convicted of any criminal offence within the past five years? YesNo d) Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? YesNo If YES, full details (e.g., name of insurer, dates) Notes NOTICE This document is a request for a Quotation for insurance only. ARGIS Pty Limited reserves the right to decline any request for Quotation for insurance. If cover is requested the insured is required to provide a signed Supplementary Declaration within 30 days of the inception date of their cover note.