Agricultural submission Farm Information Name of the farm Civic Number* Street* City* Postal Code* Province* - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Website Resource person First Name* Last Name* Phone Number* Ex. 5555555555 Email* By which method do you prefer to be contacted? Contact by* Email Telephone Information about your current insurance policy Expiry date of your policy Expiry date of your policy: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Expiry date of your policy: Day Day12345678910111213141516171819202122232425262728293031 Expiry date of your policy: Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048 Are you already insured by Groupe Promutuel?* Yes No If not, your current insurer is? Additional Information Activity(ies), Turnover, Years of experience Dairy production Gross Sales Years of experience Livestock Livestock type Gross Sales Years of experience Fruit production Gross Sales Years of experience Vegetable production Gross Sales Years of experience Field crops Gross Sales Years of experience Greenhouse Crops Gross Sales Years of experience Total land area of the enterprise Area unit* Acres Hectares Total approximate value of farm buildings Is farming your main source of income? Yes No Do you process your own products? Yes No Are you engaged in retail sales? Yes No Help us protect your information At Promutuel Insurance, keeping your information confidential is our priority. Therefore, we would like to obtain your consent to collect, use, and communicate your information. This will enable us to create quotes tailored to your needs, administer your file, and manage our insurance risks. Learn more here: Legal Notice and Confidentiality. I accept the terms and conditions.