Mid-Columbia Insurance, Inc.   P.O. Box 857   The Dalles, OR 97058

541-296-1287 or 1-800-827-1287      Fax: 541-296-5199
stan@mcin.biz   tonya@mcin.biz

Hail/Fire Worksheet

Name:
Email:
Phone:
Date:



Please complete and submit this form. Expect confirmation from us within 24 hours. Please contact us if we do not confirm.
If you encounter issues with this form, or would like a printable worksheet to submit via mail or fax, click here.

 
For Company Use
A
B
C
D
E*
F**
Crop
Farm
Name
Twp
N/S
Range
E/W
Section
Your
Share in
Crop
Acres
Estimated
Bu./Tons
per Acre
Estimated
$ per
Bu./Tons
Total
Ins./acre @
100% share
Total
Amount
of Ins.
Rate
Gross
Premium

Do you want:      Cash Discount (if applicable and paid by July 1st)? YES NO            Coverage on Home Stored Grain? YES NO

Other entities insured on your policy (please list names):

E* = C x D       F** = A x B x E
We strongly encourage you to break out your coverage by field.