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* Name * E-mail
* Address * City
* State * Zip
County Work Phone
*Home Phone
# Bedrooms # Baths Sq. Ft.
Year Built City Limits Distance to City
Water
Construction
Frame 50/50 Masonry/Frame Masonry
Dbl. Wide Mobile Home
Foundation Type
Slab Block Concrete Wall Basement
Roof Type
Asphalt Tin Flat Wood
Roof Age
Garage
Detached Attached Number of Garages
Carport
Heat Sources
Wood Outside Wood Furnace Fire Place
Gas Electric Fuel Oil
Centralized
Yes No
Number Acres
Structural Updates
Roof Electrical Plumbing
Heating List Others
Barns (List Dimensions)
1 2 3 4
5 6 7
Barn Coverage Amounts
1 2 3 4
5 6 7
Estimated Farm Personal Property Value
Scheduled Unscheduled
Total Live Stock
Winter Berths
Estimated Current R/C Home Value

Liability Limits Custom Farming
Property Rented to Others
Estimated Rental Home Value

REMARKS

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© 2009 MOCrop Insurance | Burgher Insurance
MOCrop Insurance & Burgher Insurance are equal opportunity providers. All rights reserved.

2709 E Liberty | Mexico | MO 65265
Toll Free: 1.800.633.6540
Tel: 573.581.4420 | Fax: 573.581.7264

Privacy Statement | Non-Discrimination Statement

The U.S. Department of Agriculture (USDA), MOCrop Insurance and Burgher Insurance prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs). Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (Voice and TDD).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W. Washington, DC 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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