AGRINSURANCE PROPOSAL FORM- BIRDS

Broker/Agent: Code:

Name:
Contact details:

SECTION 1: DETAILS OF PROPOSER

Name: Other names:

Identity: National ID Village ID Driving license Passport

Identification Number:
Postal:

Telephone:

Email:

FINANCIAL INSTITUTION DETAILS

Account Names:
Bank Branch Account Number

Loan amount

SECTION 2: THE FARM LOCATION

District:

County/ Division:

Sub-county/ Town:

Parish/ Ward:

Village/ Zone:

LC1 letter ((if no ID available)

Farm size:

GPS Coordinates:
(will be filled in by insurer)

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 AGRINSURANCE PROPOSAL FORM- BIRDS

SECTION 3: FARM DETAILS

1. Type of Birds: Broilers Layers Hatchery

2. Description of the birds to be insured

Unit Date of Date of No of Total no Breed Age in Source of Expected
Hatch Purchase birds of birds strain weeks at purchase date of
of birds purchase in the proposal disposal
d as per unit at
delivery proposal

3. Cost of day old chick: ________________________

4. Value per bird: _____________________________

5. What is the system of Housing of the Birds?
i. In brooding House: Deep Litter Cage system
ii. In grower House: Deep Litter Cage system
iii. In layer House: Deep Litter Cage system

6.Equipment:
i. No of feeders: ______________
ii. No of Drinkers: _____________
iii. No of Brooders: _____________

7. Is a qualified Vet. Surgeon employed to look after the farm: Yes No

8.If yes, please give his:
i. Name: ________________________________________________
ii. Qualification: ___________________________________________
iii. Regd. No. ______________________________________________
iv.Is he residing at the farm 24 hours? Yes No

9.If qualified Vet. Is not employed, then on whose services do you depend upon:
_____________________________________________________________________

10.Details of other Technical persons residing at the farm premises

Name: ___________________________
Qualification: ______________________
Job Description: ____________________
11.Are the diagnostic equipment/agents maintained at the farm: ____________________

12.Do you stock essential medicines at the farm: ________________________________

13.Do you manufacture your own feed or get it from the market: ____________________

14.Is the owner/partner/associate experienced in poultry farming Or have undergone any

training: ______________________________________________________________

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 AGRINSURANCE PROPOSAL FORM- BIRDS

15. Details of vaccination conducted during last six months:

Unit Date of Age Disease against Trade Name of Batch Vaccination
No vaccination of which vaccinated No vaccine No done
birds vaccination

16. Details of debeaking

Unit No.
Date of debeaking

17. Details of deworming

Unit No.
Date of deworming

18.Has there been any epidemic outbreak during last 3 years? If so, give details:
_____________________________________________________________________
_____________________________________________________________________
19.Do you maintain the following records?
a) Flock record on day to day basis: _______________________________________
b) Mortality record: ____________________________________________________
c) Culling: ___________________________________________________________
d) Vaccination and medication particulars: __________________________________
e) Feed consumption: __________________________________________________
f) Production: ________________________________________________________
g) Debeaking: ________________________________________________________
h) Incidence of diseases: ________________________________________________
i) Purchase and sales: __________________________________________________
20.When was the farm established? ___________________________________________
SECTION 4: INSURANCE ASPECTS
1. Have you at any time proposed your birds for insurance? If so, give name and address
of the Company: _______________________________________________________
2. Has any Company:
i. Declined to issue a policy to you? ______________________________________
ii. Declined to continue insurance? _______________________________________
iii. Not invited renewal of policy? _________________________________________
3. Period of Insurance for the present proposal: From _____________ to ___________

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 AGRINSURANCE PROPOSAL FORM- BIRDS

SECTION 5: DECLARATION
I/We agree to declare daily mortality details on weekly basis to the company.
I/We declare that the foregoing statements are true to the best of my/our knowledge and
belief, that I/We have disclosed all particulars affecting the assessment of the risk. I/We
agree that this proposal and declaration shall be the basis of contract between me/us and
the company.

Date: ___________ _________________________________

Place: ___________ Signature of the Proposer

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