Agriculture Questionnaire

Application Number:
Name of Name of Life to be Insured / Proposer: Age:

A. Details of land holding:

1. Where is the Land situated:
a. Place:
b. Survey No / Village:
c. District:
d. State:
e. Total Land under cultivation: in Acres / Hectares / Bigha /Others (Specify: )
f. Solely Owned by you Jointly Owned by you Land not owned but Only Cultivated by you
g. If Land is Jointly Owned by you, please provide the following details:
Area Share of Land owned by you ____________________________________________ ( specify area of land )
% of Share owned by you
Number of Owners of the Land
Relationship with the shared Land Owners
h. Land not owned by you but only cultivated by you: ( Please provide below name of the owner and submit relevant document if available ) : Any profit sharing/lease
agreement if Land is not owned but farming is only cultivated by you:

B. Details of Crops / Fruits / Vegetables grown:-

Sr. Crop Name Area under Season of crop grown No. of times the Yield of Crop Market Value of
No cultivation crop is grown Quintal In the Crop
(1 Quintal = 100 Kg) (per quintal)

C. Details of Cultivation :-
1. Since how many years the land is under cultivation? years
2. Type of Irrigation used for farming (example: Well water irrigation, Tank water irrigation, Canal Irrigation, Perennial Canals Irrigation etc...). :

3. Does the land under cultivation has continuous water supply:

4. Has there been any droughts/floods/any other natural calamities in the last 3 years which has affected your yield?
5. Do you sell the produce directly to Government or Private / Public Limited Company: Yes No
If yes, please provide details of the organization / department details:

6. Where do you sell the agricultural produce? (Provide name of APMC market / Mandi / Open market/ Co-operative society/ corporate houses / Exports etc.):

7. Provide the name, address of the commission agent / purchaser of the produce:
8. Do you file: Income tax Yes / NO Wealth tax Yes / NO Property tax Yes / NO
9. Any other source of income apart from the agriculture? If so, please give details.

10. Do you hold below the poverty line ration card / Family card? Yes / NO
11. Whether you or your family are availing any subsidiary benefits provided by the government:

12. Please provide the following details:-

Details of Farm Machinery Used
(Such as Tractor, Harvesting machines etc...)
Details of Livestock
(Farm animals like cattle, sheep etc.)

1
D. 1. Bank Account Details:
Name of Bank
Bank Account Number
Account Opening Date

D. 2. Details of Agricultural Loan :

Name of Bank / Institution
Amount of Loan opted ________________ _____ /-
Duration of the Loan ___________________ years/months
Frequency of Payment (Yearly, Half-Yearly, Quarterly, Monthly )
Outstanding Amount _____________________ /-

E. Please mention your total gross annual income for the last 3 years. In case of profit sharing arrangement please mention amount of your
share of profit made for the last three years:

Year Annual Income earned

Signature of Life Insured / Proposer:

Date: D D M M Y Y Y Y Place:

VERNACULAR DECLARATION: (In case Life Insured/Proposer signs in Vernacular Language / Thumb impression)

I _____________________ holding _____________ (ID Card type) with number_________________ (ID Card number) hereby declare that I have explained
the contents of this declaration to the Proposed Insured/Applicant in _____________________ language and that the Proposed Insured /Applicant has
affixed his/her signature/thumb impression after fully understanding the contents thereof.

Signature/Thumb impression of Witness Signature

Life Insured/Proposer
Date: D D M M Y Y Y Y Place:

Kindly provide 7/12 Extract OR Land Records alongwith Form J/Mandi receipts/Patwari Book/Tehsildar certificate etc.. as a supportive document
alongwith Agriculture Questionnaire

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