Inland Marine/Irrigation Worksheet
Client Name:
Applicant's Email:
Agent:
Prior Losses - Past 3 Years
1 Prior Loss
2 Prior Losses
3 Prior Losses
4 Prior Losses
No Prior Losses
Prior 3 Year Loss Ratio
Less than 150%
Greater than 150%
Occurance Deductible
$1000
$2,500
$5,000
$10,000
Does the applicant request coverage for certified acts of terrorism as provided by the Terrorism Risk Insurance Act of 2002 for an additional policy premium charge of $100?
Yes
No
Locations:
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Total Irrigation Values:
Total Proposed Values:
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