Winery Insurance Application

General Information
Date: ____________________________________                Policy Effective Date:_________________________________
Name:___________________________________________________________________________
Address:_________________________________________________________________________
City:________________________            State:_____            County:____________________        Zip:__________________
Office Phone:______________________________            Fax:________________________________   Other:___________________________
Website:________________________________
E-Mail:__________________________________
Contact Person:__________________________________________________
Years in Business:_________                   If Less than Three Please Provide Resume of Principals
Federal Tax ID Number:___________________________
Applicant is:          __Individual              __Corporation                  __Other_________________________

Coverage Sections Requested:    __Property                     __General Liability                    __Workers Compensation                    __Automobile
                                                                 __Liquor Liability       __Umbrella Liability                 __Crop Insurance                                      __Equipment Breakdown

Property Insurance

Building 1 Address:_________________________________________             
                                      City:________________        State:__        County:_______________        Zip:____________
                                      Construction: ____ Frame____ Metal____ Masonry            Year Built:______        Square Feet:________________
                                     If over 25 Years Old Please Indicate Year Of Improvement For     Heating______   Electrical______    Plumbing______
                                                                                                                                                                      Roofing______
                                    Number of Stories:_____            Basement:___Y ___N            Fire Sprinklers:___Y___N            Alarm:___Y___N
                                    Building:_____Owned   ____Leased
                                    Please Describe How Building is Used:___________________________________________________
                                    Business Personal Property Insurance Coverage Limit:_______________________________________
                                    Building Replacement Cost Limit if Applicable:____________________________________________
                                    Distance to Fire Department:______Miles    Distance to Fire Hydrant:_________Feet
                                    If No Fire Hydrant Within 1000 Feet Please Indicate If There Is An Alternative Source of Water:___Y ___N
                                    If Yes:  Number of Gallons Per Minute Available:________    Can Fire Department Hook Up To It:___Y ___N

Building 2 Address:_________________________________________             
                                      City:________________        State:__        County:_______________        Zip:____________
                                      Construction: ____ Frame____ Metal____ Masonry            Year Built:______        Square Feet:________________
                                     If over 25 Years Old Please Indicate Year Of Improvement For     Heating______   Electrical______    Plumbing______
                                                                                                                                                                      Roofing______
                                    Number of Stories:_____            Basement:___Y ___N            Fire Sprinklers:___Y___N             Alarm:___Y___N
                                    Building:_____Owned   ____Leased
                                    Please Describe How Building is Used:___________________________________________________
                                    Business Personal Property Insurance Coverage Limit:_______________________________________
                                    Building Replacement Cost Limit if Applicable:____________________________________________
                                    Distance to Fire Department:______Miles    Distance to Fire Hydrant:_________Feet
                                    If No Fire Hydrant Within 1000 Feet Please Indicate If There Is An Alternative Source of Water:___Y ___N
                                    If Yes:  Number of Gallons Per Minute Available:________    Can Fire Department Hook Up To It:___Y ___N

Building 3 Address:_________________________________________             
                                      City:________________        State:__        County:_______________        Zip:____________
                                      Construction: ____ Frame____ Metal____ Masonry            Year Built:______        Square Feet:________________
                                     If over 25 Years Old Please Indicate Year Of Improvement For     Heating______   Electrical______    Plumbing______
                                                                                                                                                                      Roofing______
                                    Number of Stories:_____            Basement:___Y ___N            Fire Sprinklers:___Y___N             Alarm:___Y___N
                                    Building:_____Owned   ____Leased
                                    Please Describe How Building is Used:___________________________________________________
                                    Business Personal Property Insurance Coverage Limit:_______________________________________
                                    Building Replacement Cost Limit if Applicable:____________________________________________
                                    Distance to Fire Department:______Miles    Distance to Fire Hydrant:_________Feet
                                    If No Fire Hydrant Within 1000 Feet Please Indicate If There Is An Alternative Source of Water:___Y ___N
                                    If Yes:  Number of Gallons Per Minute Available:________    Can Fire Department Hook Up To It:___Y ___N

Building 4 Address:_________________________________________             
                                      City:________________        State:__        County:_______________        Zip:____________
                                      Construction: ____ Frame____ Metal____ Masonry            Year Built:______        Square Feet:________________
                                     If over 25 Years Old Please Indicate Year Of Improvement For     Heating______   Electrical______    Plumbing______
                                                                                                                                                                      Roofing______
                                    Number of Stories:_____            Basement:___Y ___N            Fire Sprinklers:___Y___N             Alarm:___Y___N
                                    Building:_____Owned   ____Leased
                                    Please Describe How Building is Used:___________________________________________________
                                    Business Personal Property Insurance Coverage Limit:_______________________________________
                                    Building Replacement Cost Limit if Applicable:____________________________________________
                                    Distance to Fire Department:______Miles    Distance to Fire Hydrant:_________Feet
                                    If No Fire Hydrant Within 1000 Feet Please Indicate If There Is An Alternative Source of Water:___Y ___N
                                    If Yes:  Number of Gallons Per Minute Available:________    Can Fire Department Hook Up To It:___Y ___N

Building 5 Address:_________________________________________             
                                      City:________________        State:__        County:_______________        Zip:____________
                                      Construction: ____ Frame____ Metal____ Masonry            Year Built:______        Square Feet:________________
                                     If over 25 Years Old Please Indicate Year Of Improvement For     Heating______   Electrical______    Plumbing______
                                                                                                                                                                      Roofing______
                                    Number of Stories:_____            Basement:___Y ___N            Fire Sprinklers:___Y___N             Alarm:___Y___N
                                    Building:_____Owned   ____Leased
                                    Please Describe How Building is Used:___________________________________________________
                                    Business Personal Property Insurance Coverage Limit:_______________________________________
                                    Building Replacement Cost Limit if Applicable:____________________________________________
                                    Distance to Fire Department:______Miles    Distance to Fire Hydrant:_________Feet
                                    If No Fire Hydrant Within 1000 Feet Please Indicate If There Is An Alternative Source of Water:___Y ___N
                                    If Yes:  Number of Gallons Per Minute Available:________    Can Fire Department Hook Up To It:___Y ___N

Wine Making Equipment

Processing Equip0ment Valuation:    Presses: $___________        Crushers: $__________        Filters: $_________        Fermentation: $_________
                                                                          Pumps: $_________        Hoses: $_________        Bottling Line: $_________        Lab Equipment: $_________
                                                                          Tasting Room Equipment: $_________        Refrigeration: $_________
                                                                          Wooden Tanks: $________        Stainless Steel Tanks: $_________      Plastic Tanks: $_________
Value or Percentage per Location: Building 1:_________    Building 2:_________    Building 3:_________    Building 4:_________    Building 5:________

Other Property

Computer Hardware Including Telephone and Data Processing Equipment: $_________
Agricultural Equipment: $_________  Please Attach Itemized Schedule of Equipment if Total Value Exceeds $20,000 or Individual Items Exceed $5,000

Wine & Grapes Market Value

Value of finished wine held for retail sale                      $_________________________
Value of finished wine held for wholesale sale            $_________________________
Value of wine in process                                                        $_________________________
Bottles and bottling inventory                                             $_________________________
Library Inventory                                                                       $_________________________
Value all categories at selling price.  Please indicate approximate percentage of total values at each property location.
Building 1___________    Building 2___________    Building 3____________    Building 4____________    Building 5____________

General Liability Insurance

Liability Limit Per Occurrence:        __________________________
Liability Limit Annual Aggregate:    __________________________
Medical Payments                                 __________________________
Umbrella Liability Limit                      __________________________
Liquor Liability Limit                           __________________________

Automobile Insurance

Vehicles:
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Year:_______    Make/Model:___________________    VIN:__________________________    Cost New:_____________    Garaging City:_______________
Bodily Injury Liability Limit:    $_________________per person/$__________________ per accident   $________________ property damage
Comprehensive deductible $__________        Collision deductible $_________    Radius of operations _______Miles
Do employees operate own vehicles in your business  ___Y    ___N
List of Drivers
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____
Name:______________________    Date of Birth:________________    SS#:____________________  DL#___________________    State____

Underwriting Questions

Total acres owned or leased:______________________        Vineyard acres:_____________________    Other crops:_______________________
Are you responsible for shipments of finished goods until they arrive at your customer?    ___Y  ___N
If so, largest value per shipment via common carrier:    $___________________
Sales Breakdown:  Please list your approximate annual sales per category
                                     Wine Retail:                   $________________________
                                     Wine Wholesale:          $________________________
                                     Tasting Room Sales:    $________________________
                                     Restaurant Sales:         $________________________
Total Annual Payroll:    $______________________
Total Employees:               ______________________
Do You Sell Across State Lines  ___Y ___N
Do You Sell To Canada                  ___Y ___N
Do You Custom Crush?                 ___Y ___N        If So, Annual receipts $________________

Current Policy and Losses

Liability            Carrier:____________________    Expires on:____________________    Policy Number:________________    Premium:___________
Property          Carrier:____________________    Expires on:____________________    Policy Number:________________    Premium:___________
Automobile    Carrier:____________________    Expires on:____________________    Policy Number:________________    Premium:___________
Umbrella         Carrier:____________________    Expires on:____________________    Policy Number:________________    Premium:___________

Claims History for past three years        ___Check here if none
Date:__________________    Circumstance:_________________________________    Payment:___________________________
Date:__________________    Circumstance:_________________________________    Payment:___________________________
Date:__________________    Circumstance:_________________________________    Payment:___________________________
Date:__________________    Circumstance:_________________________________    Payment:___________________________
Please provide three year loss runs from current carriers

Signature:        ______________________________  Owner or executive            Date:_________________________
Printed Name:______________________________  Title:_________________________