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Please enter your insurance agent's information here.Agent Name*Agent Number*Agent Email* Agent Phone Number* Contact InfoMembership Number* First Name Middle Name Last Name Birthdate* MM slash DD slash YYYY Spouse's First NameSpouse's Last NameSpouse's Birthdate MM slash DD slash YYYY Email* Membership County*ADAMSALLEGHENYARMSTRONGBEAVERBEDFORDBERKSBLAIRBRADFORDBUCKSBUTLERCAMBRIACAMERONCARBONCENTRECHESTERCLARIONCLEARFIELDCLINTONCOLUMBIACRAWFORDCUMBERLANDDAUPHINDELAWAREELKERIEFAYETTEFORESTFRANKLINFULTONGREENEHUNTINGDONINDIANAJEFFERSONJUNIATALACKAWANNALANCASTERLAWRENCELEBANONLEHIGHLUZERNELYCOMINGMCKEANMERCERMIFFLINMONROEMONTGOMERYMONTOURNORTHAMPTONNORTHUMBERLANDPERRYPHILADELPHIAPIKEPOTTERSCHUYLKILLSNYDERSOMERSETSULLIVANSUSQUEHANNATIOGAUNIONVENANGOWARRENWASHINGTONWAYNEWESTMORELANDWYOMINGYORKHome Phone*Work PhoneCell PhoneAddress* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Township(s) you are located in Business/Farm InfoBusiness/Farm NameSize of Farm Operation- Select -SmallMid-SizeLargeCommodities ProducedNo Commodities ProducedAlpacasAnimal Breeders - GeneralAnimal Breeders - Small AnimalsApiary - Bee KeeperApiary - HoneyApplesApples/FreshApples/ProcessedAquaculture - Bait FishAquaculture/Fish FarmingArtificial BreederBeef - GeneralBeef - VealBeef CattleBerries - GeneralBerries - StrawberriesBisonBreweryButcherCanine BreedersChristmas TreesCorn - GeneralCorn - H.M. 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To discontinue auto-renewal billing, I understand that I must notify Pennsylvania Farm Bureau by one of the below contact methods, at least one week prior to the auto-renewal billing date. The exact auto-renewal date (generally September 15) will be provided in an annual reminder email. I understand refunds will not be issued after a payment has processed. Contact methods: Phone—717.761.2740; Email—member@pfb.com; Mail—PA Farm Bureau, Attn: Member Services, 510 S. 31st Street, PO Box 8736, Camp Hill, PA 17001-8736. 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