COMBINATION PACKAGE APPLICATION - Norwegian Mutual · This is not Commercial Liability, consult your Agents Manual or Company for Commercial Coverages. LIABILITY - PERSONAL LIABILITY

COMBINATIONPACKAGE APPLICATION

_________________________________________ _________________________________________ AND _________________________________________

Fire Policy Number: NAME AND ADDRESS: Indv.   Part.   Corp. Other_____ NEW RENEWAL OF __________________________________ FROM:_______________________ TO:__________________________ City: MN Zip Code: Phone #: Name: Social Security #: Name: Social Security #:

PERILS INCLUDED:   Fire Windstorm and Hail FPL PL Inland Marine Other__________________________ DEDUCTIBLE:   $100 $250   $500 $1,000 (Base) $2,500 $5,000 $10,000

MORTGAGEE C/D   NAME AND ADDRESS: MORTGAGEE C/D   NAME AND ADDRESS:

DESCRIPTION OF PREMISES: List all property with buildings owned, leased, rented or maintained. List primary location 1st. Loc. No. of Sets of Qtr. Sec-Twp-Range Int No. Dwlgs. Bldgs. Acres Sec. Numbers Township County State (O/T) 911 Address Latitude/Longitude 1 2 3 4 Bare Land Total Additional Acres - with no buildings - owned, leased, rented or maintained not listed above. TOTAL ACRES

UNDERWRITING GUIDE - FURNISH PHOTOS OF ALL BUILDINGS All questions must be answered or app. may be returned. If asked to explain or list, please list question no. & information on a separate memo & attach. 1. Date of last on-site inspection:__________________ By whom? __________________________________________________________________ 2. Principal farm operations are:   Grain Dairy   Livestock Poultry Occupation: _______________________________________ 3. General housekeeping and condition of premises:    Excellent Good Fair   Poor 4. DWELLING: A. Age_____Yrs. B. Smoke Alarm(s): Yes No C. Fire Extinguisher(s): Yes No D. Wiring______Yrs.; #Amps: ____ E. Plumbing_____Yrs. F. Occupancy:   Owner Tenant Unoccupied Vacant Seasonal Under Construction ________ G. Central Heating: Yes No; Age of Heating Unit(s)________Yrs.; Type: _____________________________________________ H. Any type of solid fuel heating equip: Yes No; Type: Central Space Fireplace; Age_____Yrs.; Type of Chimney ________ I. Roof: Age_____Yrs. Type: Asphalt Shingles Wood Shakes or Shingles Metal Other: ___________________________ J. Solar Heating: Yes No; If yes, explain on a separate memo. K. Wind Generating Equipment:   Yes No 5. OUTBUILDINGS: If an answer to a question is yes, list the building(s) and explain on a separate memo and attach. A. Occupied by:  Owner Tenant Off Premises Tenant B. Condition of buildings:   Excellent Good Fair Poor C. Any building not used for designed purposes? Yes No D. Do any outbuildings have: Heating? Yes No; Exposed Insulation? Yes   No; Existing Damage? Yes   No E. Condition of wiring in buildings: Excellent Good Fair Poor F. Are buildings unused or vacant? Yes   No G. Are there any buildings where wind coverage should be: Restricted? Yes No; Omitted? Yes   No 6. PL/FPL SURVEY: A. Does applicant have: Seasonal Property? Yes   No;  Business Office or Incidental Sales?    Yes   No; Rental Property? Yes No; Trampoline? Yes No; Roadside Stand?   Yes No; If yes, explain on a separate memo. B. Swimming Pool? Yes No; Above Ground or Below Ground; Diving Board/Slide?   Yes No; Fence around pool? Yes No; (Provide Picture of Pool). C. Does applicant do custom farming? Yes No; Type________; Custom Spraying involved? Yes No; Gross Annual Custom Farming Receipts?_____________________ D. Are premises used for any business or professional purposes other than farming?   Yes No: If yes, explain on a separate memo. E. Does applicant own any livestock?   Yes No F. Are there horses on premises?   Yes No; Owned? Yes No; #________; Type:_____________________________ Boarded?   Yes No; #_______; Type:____________________________ G. Does applicant own dog(s)   Yes No; If yes, what breed(s)?_____________________________________________; Has the dog(s) ever bitten anyone?   Yes No H. In what condition are applicant's fences?   Good   Fair   Poor I. Do all steps have adequate handrails? Yes No J. Condition of farm equipment:   Good     Average   Poor; Has safety equipment been altered or removed? Yes   No 7. PREVIOUS CARRIER: Was policy cancelled or non-renewed? Yes  No; If yes, why? 8. OTHER INSURANCE: A. Is there other insurance? Yes No; If yes, with whom? B. Is there other insurance with NORTH STAR? Yes No; If yes, policy number(s): 9. How long has Agent personally known applicant? Does Agent personally recommend issuance of this policy? Yes No

LOSS EXPERIENCE: NONE APPLICANT'S SIGNATURE WIND COMPANY ONLY Und. D.E. Checker

GENERAL AGENTS USE ONLY GA's Initials ___________________ AGENCY ________________________________AGT. NO _______   Application has been reviewed and approved. Comments: _________ AND ______________________________________________ ___________________________________________________________ ADDRESS ______________________________________________ E-MAIL ADDRESS

List all losses in last 5 years and any losses ever over $10,000. (Dates, Type & Amount)

(12:01 a.m. at address of named insured)BILLING MODE: Annual Semi-Annual Quarterly Other____BILL PREMIUM TO: Insured Agency Mortgagee

Box 48 Cottonwood, Minnesota 56229

- 1 -

CODE AMOUNT DESCRIPTION Fire/Wind

CLASS A-1 and A-5 RESIDENCE A-1 Delux Dwelling: Basic Broad Special A-5 "Delux Dwelling Plus":  Special______ ______ $ _______________ Residence______ ______ $ _______________ Household Personal Property______ ______ $ _______________ Additional Living Expense $ _______________ Sub-Total

Metal Roof Discount (Cosmetic Damage Exclusion applies) Replacement Cost - Household Goods (Option - Delux Dwelling Only) Special Form - Household Goods (Option - Delux Dwelling Only)

FIRE PROTECTION APPLYING Protected Partially Protected Unprotected

CLASS A-2 DWELLINGS Limited Basic Broad Special______ ______ $ _______________ Dwelling ________ _____x___________ ______ $ _______________ Household Personal Property______ ______ $ _______________ Additional Living Expense $ _______________ Sub-Total

Metal Roof Discount (Cosmetic Damage Exclusion applies) Replacement Cost - HHGs Special Form - HHGs

CLASS A-3 MOBILE HOMES Limited Basic Broad ______ ______ $ _______________ Home (Age/Make) _____x___________ ______ $ _______________ Additions ________ _____x___________ ______ $ _______________ Household Personal Property______ ______ $ _______________ Additional Living Expense $ _______________ Sub-Total

Replacement Cost - Household Goods

CLASS E SCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad Special - Farm Mach. $_____________ ______ $ _______________ Scheduled Farm Personal Property (From 7 on Opposite Page)______ ______ $ _______________ Portable Crop or Grain Dryers______ ______ $ _______________ ___________________________________ ______ $ _______________ _____________________________ $ Sub-Total

CLASS F UNSCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad Special - Farm Mach. $_________________ ______ $ _______________ Unscheduled Farm Personal Property (From 8 on Opposite Page)

CLASS G-1 FARM BARNS, BLDGS, STRUC (Superior) Replacement Cost Provisions, Weight of Ice, Sleet & Snow and Special Form Included (Min - 90% of Full Replacement Cost Required)______ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______ $ _____________ ______________ _____x___________ ______ $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x_____

G-1S______ ______ $ _____________ ______________ _____x___________ ______  $ _____________ ______________ _____x___________ ______ $ _____________ ______________ _____x_____ $ Sub-Total

- 2 -

CODE AMOUNT DESCRIPTION Fire/Wind

CLASS G-2 FARM BARNS, BLDGS, STRUC (Above Avg.) Weight of Ice, Sleet & Snow Included (Minimum - 50% of Full Replacement Cost) Limited Basic______ ______ $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x_____

G-2S______ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x_____   $ Sub-Total

CLASS G-3 FARM BARNS, BLDGS, STRUC (Standard) (Minimum - 25% of Full Replacement Cost)

Limited Basic______ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x___________ ______  $ ______________ ______________ _____x_____ $ Sub-Total

CLASS H SPECIAL HAZARD & LOW VALUE OUTBUILDINGS Limited Basic______ ______ $ _______________ ________________ _____x___________ ______ $ _______________ ________________ _____x___________ ______ $ _______________ ________________ _____x___________ ______ $ _______________ ________________ _____x_____ $ Sub-Total

MISCELLANEOUS PROPERTY CLASS Limited Basic

______ ______ $ _______________ ________________ _____x___________ ______ $ _______________ ________________ _____x_____ $ Sub-Total

OPTIONAL COVERAGES Yes/No______ ______ $ _______ Total Fire Dept. Serv. (Fire Co. Only)______ ______ $ _______ Submersible Pumps______ ______ $ _______ Underground Wiring______ ______ $ _______ Farm Operations Records Cov.______ ______ $ _______ Peak Season - Item:______________ From:__________ To:_________________ ______ $ _______ Loss of Income (Dairy and Hogs)______ ______ $ _______ Farm Extra Expense______ ______ $ _______ Leased, Rented or Borrowed Farm Machinery Coverage______ ______ $ _______ Identity Fraud Expense______ ______ $ ___________________________________________ ______ Blizzard Death (Livestock)______ ______  Livestock Confinement Coverage (Separate Application Required)______ ______ Special Package of Coverages - 2nd Unit______ ______ Super Star Credit______ ______ Companion Policy Discount Auto Policy # ___________________________

$______________ GRAND TOTAL COVERAGE

xCF-2018

CosmExcl

Applies

CF-2018CosmExcl

Applies

CF-2018CosmExcl

Applies

FARM PERSONAL PROPERTY INVENTORY

SCHEDULED FARM PERSONAL PROPERTY UNSCHEDULED FARM PERSONAL PROPERTY

- 3 -

LIVESTOCKCATTLE # Value Total Dairy Cows ______@______ $ ______________ Heifers ______@______ $ ______________ Dairy Calves ______@______ $ ______________ Feeder Cattle ______@______ $ ______________ Stock Cattle ______@______ $ ______________ Bulls ______@______ $ ______________ Registered Cattle ______@______ $ ______________SHEEP Ewes ______@______ $ ______________ Rams ______@______ $ ______________ Lambs ______@______ $ ______________HOGS Sows ______@______ $ ______________ Boars ______@______ $ ______________ Feeder Pigs ______@______ $ ______________HORSES ______@______ $ ______________

1 TOTAL LIVESTOCK ....................... $

POULTRYHens ______@______ $ ______________Fryers ______@______ $ ______________

2 TOTAL POULTRY ........................... $

HAY, STRAW AND FODDERHay ______@______ $ ______________Straw ______@______ $ ______________Fodder/Silage ______@______ $ ______________

3 TOTAL HAY, STRAW & FODDER .. $

GRAIN, FEED AND SUPPLIESCorn ______@______ $ ______________Soybeans ______@______ $ ______________Wheat ______@______ $ ______________Oats ______@______ $ ______________Sunflowers ______@______ $ ______________Farm Chemicals ______@______ $ ______________Veterinary Supplies ______@______ $ ______________Fuel, Oil & Grease ______@______ $ ______________Paints ______@______ $ ___________________________________ ______@______ $ ___________________________________ ______@______ $ ___________________________________ ______@______ $ ______________Commercial Feed ______@______ $ ______________Ground Feed ______@______ $ ______________

4 TOTAL GRAIN, FEED & SUP. ........ $

FARM MACHINERY AND EQUIPMENTTractors: ValueNo. 1 ____________________ $ ______________No. 2 ____________________ $ ______________No. 3 ____________________ $ ______________No. 4 ____________________ $ ______________No. 5 ____________________ $ ______________No. 6 ____________________ $ ______________Garden Tractor ____________ $ ______________Skid Loader _______________ $ _______________________________________ $ ______________Combine No. 1 _____________ $ ______________Combine No. 2 _____________ $ ______________Combine Heads ____________ $ ______________Combine Heads ____________ $ ______________Swather __________________ $ _______________________________________ $ _______________________________________ $ ______________Other Self Propelled:_________________________ $ ______________Port. Elevator ______________ $ ______________Port. Auger No. 1 ___________ $ ______________Port. Auger No. 2 ___________ $ _______________________________________ $ ______________

Bale Racks & Trailers _______ $ ______________Beet Defoliators ____________ $ ______________Beet Lifters _______________ $ ______________Beet Planters ______________ $ ______________Beet Thinners _____________ $ ______________Chisel Plow _______________ $ ______________Corn Planter ______________ $ ______________Crop Sprayer ______________ $ ______________Drill Seeder _______________ $ ______________Disc _____________________ $ ______________Drag _____________________ $ ______________Fert. Spreader _____________ $ ______________Field Cultivator _____________ $ ______________Grain Wagons _____________ $ ______________Grinder/Mixer/Mill __________ $ ______________Hay Baler _________________ $ ______________Hay/Crimper/Bine __________ $ ______________Hay Stacker Loader _________ $ ______________Hay Stack Mover ___________ $ ______________Livestock Trailer (Unlicensed) _ $ ______________

Mach. Trailer (Unlicensed) ____ $ ______________Manure Spreader ___________ $ ______________Mower ___________________ $ ______________Plows ____________________ $ ______________Potato Digger ______________ $ ______________Rakes ___________________ $ ______________Rotary Tiller/Hoe ___________ $ ______________Row Cultivator _____________ $ ______________Silage Wagon _____________ $ ______________Silage Cutter/Blower ________ $ ______________Stalk Cutter _______________ $ ______________Snow Blower ______________ $ ______________Spraying Tank _____________ $ ______________Tractor Loader _____________ $ ______________Vaculator _________________ $ ______________

TOOLS AND MISC. EQUIPMENT: Electric Motors ___________ $ ______________ Fuel Tanks ______________ $ ______________ Port. Generator __________ $ ______________ Spare Parts _____________ $ ______________ Power Tools _____________ $ ______________ Hand Tools ______________ $ ______________ Welder _________________ $ ______________ Compressor _____________ $ ______________ Bldg/Fencing Material _____ $ ______________ _______________________ $ ______________ _______________________ $ ______________ _______________________ $ ______________ _______________________ $ ______________ _______________________ $ ______________ _______________________ $ ______________

5 TOTAL FARM MACHINERYAND EQUIPMENT .............. $

INSTALLED EQUIPMENT(Must be Scheduled if not included

in building value)

Bulk Tank/Cooler __________ $ ______________ Milk House Equip. _________ $ ______________ Milking Mach. Equip. _______ $ ______________ Hog House Equip. _________ $ ______________ Poultry Equipment _________ $ ______________ Silo Unloader _____________ $ ______________ _______________________ $ ______________ _______________________ $ ______________

6 TOTAL INSTALLED EQUIPMENT .............. $

Policy provisions require individual scheduling of above items when not being used in Unsched-uled Farm Personal Property. Following items may be optionally scheduled.

7 TOTAL SCHEDULED VALUE 8 TOTAL UNSCHEDULED VALUE (Add 1 through 6 - transfer amount to page 2) $_______________ (Add 1 through 5 - transfer amount to page 2) $______________Comments:

INLAND MARINE COVERAGE - Attach Completed Inland Marine Application

This is not Commercial Liability, consult your Agents Manual or Company for Commercial Coverages.LIABILITY - PERSONAL LIABILITY (PL) OR FARM PERSONAL LIABILITY (FPL)

COVERAGE LIMITS: Coverage L - Personal Liability:_________________ Coverage M - Medical Payments to Others:_________________Cov. Applies Limits of Liability Med Pay Each Yes/No (Med Pay 1,000 Included) $50,000 $100,000 $300,000 $500,000 $1,000,000 Add'l $500 Premium

  BASE PL CHARGE (1 family) 43.00 47.00 63.00 78.00 117.00 3.00 $ ________

  BASE FPL CHARGES - Including Employer's Liability for part time employees working 40 days or less per year 320 acres or less, 1 dwelling, 1 set of buildings 101.00 110.00 147.00 176.00 264.00 3.00 $ ________ 321 - 1000 acres, 1 dwelling, 1 set of buildings 116.00 129.00 168.00 202.00 303.00 3.00 $ ________ Over 1000 acres, 1 dwelling, 1 set of buildings 131.00 144.00 190.00 231.00 347.00 3.00 $ ________   Non-Farming Discount (Farm land not operated by insured/no making of hay and with 5 or less head of horses/other livestock) - Reduce the Base acres charge by 50% $ ________ ADDITIONAL CHARGES   Add'l Farm Premises with Bldgs. No._____ (Owned or Rented) 14.00 16.00 19.00 22.00 33.00 2.00 $ ________   Additional Residence Premises Maintained No._________ 8.00 9.00 12.00 14.00 21.00 2.00 $ ________ (Secondary Locations, Seasonal Dwgs.) Location:     Incidental Office - Describe__________________________  9.00  11.00  13.00  15.00  23.00  2.00  $ ________   Livestock Owned - Liability Exposure Charge 57.00 63.00 70.00 77.00 116.00 6.00 $ ________   Babysitting (1-5 children) (1 charge) No. of Children______ N/A N/A 74.00 81.00 122.00 3.00 $ ________   Custom Farming, Per $100.00 of Receipts 0.80 0.90 1.15 1.40 2.10 0.07 $ ________ (When Custom Farming exceeds $1,000, charge applies to receipts in excess of $1,000) Estimated Receipts $____________     Horses (1-2 Included)  (If over 10 horses, refer to Home Office)  (Horses taken to parades or shows?  Yes No) 3-5 25.00 30.00 35.00 40.00 60.00 3.00 $ ________ 6-10 50.00 60.00 70.00 80.00 120.00 4.00 $ ________   Inboard or Inboard/Outboard Motor Boats 30 M.P.H. & Under and Less than 26 feet 19.00 22.00 29.00 33.00 50.00 3.00 $ ________ Over 30 M.P.H. and Less than 26 feet 46.00 52.00 69.00 77.00 116.00 6.00 $ ________ Length________ Description________________________________________ Rated Speed (M.P.H.)________ H.P.________   Outboard Motor Boats (Standard Policy includes 50 H.P. and Under. “Delux Dwelling Plus” includes 100 H.P. and Under.) H.P.________ Make___________________________ 13.00 16.00 20.00 24.00 36.00 4.00 $ ________ Note: For rating purposes, combine the H.P. of all outboard motors used together with any single watercraft owned by the insured.   Partnership Endorsement, each Partner 22.00 24.00 31.00 38.00 57.00 3.00 $ ________ (1 Base FPL Charge plus this for each additional partner) Name:________________________ Relationship:________________________ Resides at Farm No.:____________________ Name:________________________ Relationship:________________________ Resides at Farm No.:____________________   Personal Injury (Does not include Medical Payments) 12.00 15.00 19.00 21.00 32.00 -- $ ________   Recreational Vehicles (Does not cover any 2 wheel vehicles) List Snowmobile(s) CC's_______ List ATV(s) CC's________ Snowmobiles and ATVs (1 premium charge) 50.00 52.00 67.00 75.00 113.00 6.00 $ ________   Residence Premises Rented to Others No:_____________ 1 Family - Location: 13.00 15.00 18.00 20.00 30.00 2.00 $ ________ 2 Family - Location: 26.00 30.00 35.00 38.00 57.00 4.00 $ ________   Trampoline $ ________   EMPLOYER'S LIABILITY (This does not replace Worker's Compensation coverage that may be required.) EACH FULL TIME EMPLOYEE, No.__________ 25.00 27.00 34.00 37.00 56.00 4.00 $ ________ (working 180 days per year or more) EACH PART TIME EMPLOYEE, No.__________ 15.00 16.00 19.00 21.00 32.00 4.00 $ ________ (working over 40 days but less than 180 days per year)   DAMAGE TO PROPERTY OF OTHERS - $1,000 limit included (cannot be increased if custom farming is done) $10 per $1,000 of increase (maximum $10,000) Limit $________________ $ ________   FARMER'S MEDICAL PAYMENTS - DESIGNATED INSUREDS AGES 12-65 ($100 Deductible) Limit each person: $1,000 - $46 $2,000 - $58 $3,000 - $69 NAME DOB RELATIONSHIP $ ________ Limit $_____________________________ _______________________________________________      _______________________________________________   OTHER ___________________________________________________________________________________________ $ ________ FOR COVERAGES OR RATING SITUATIONS NOT SHOWN, REFER TO HOME OFFICE TOTAL PREMIUM $AGREEMENT AND SIGNATURE OF APPLICANT AND AGENT - The signatures below certify that: (1) All property under Class E is listed to at least 80% of actual cash value. (2) Class F Property is insured to 100% of the Inventory Schedule. The applicant understands that an 80% coinsurance requirement applies and agrees to, at all times, maintain contributing insurance onthepropertyinsuredtotheextentofatleast80%ofitsactualcashvalue,andfailingtodoso,shalltotheextentofanydeficitbeartheproportionofanyloss.(3)AllClassG-1structuresare insured to at least 90% of replacement value. (4) All Class G-2 structures are insured to at least 50% of replacement value. (5) The Farm Personal Property Inventory contains a full description of the total values of the property listed. (6) The answers to questions on this application are true, correct and complete representations. (7) The check box “Yes/No” areas ac-curatelyindicatedesiredcoverage.(8)(InflationProtection)“DeluxDwelling”and“DeluxDwellingPlus”dwellingcoveragesandG-1outbuildingcoverageswillautomaticallybeupdatedonanniversary based on changing dwelling/building construction cost factors. (9) As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting departments of the Township Mutual listed on the front and North Star Mutual to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit (or credit-based insurance score), character, and/or condition of the property represented on this application. I understand that I have the right to make a request in writing as to the nature of any such information that may be developed and that I have the right to request that any such information be corrected by providing documented support for such correction. If my request is denied, I understand that I have the right to appeal to the Minnesota Commissioner of Commerce, 85 7th Place East, Suite 500, St. Paul, MN 55101-2198. I understand that this temporary authorization will expire as soon as one of the following occurs: (a) The above named companies make the underwriting decision(s) in question, or (b) one year elapses after the date I sign this authorization. However, if a policy is issued, I authorize the above permission for subsequent amendments and renewals as long as the policy remains in force.If this application for insurance is accepted, I grant permission to the Township Mutual and North Star Mutual to disclose information to the Mortgagee(s) or Loss Payee(s) that may be designated in this application or its(their) successor(s). (Reports prepared by insurance-support organizations may be retained by them and disclosed to others.)INSURANCE FRAUD IS A CRIME - I understand that a person who submits an application or claim information with intent to defraud an insurer is guilty of a crime.Applicant's Signature __________________________________________________________________________ Date ______________________As the Agent for the applicant, I attest that the information in this application and attachments is correct to the best of my knowledge. Agent's Signature _____________________________________________________________________________ Date ______________________ - 4 -CF-1000 (Ed. 4-13)

Yes/No TP1 General Policy Provisions Q Added Perils for Refrigerated Food Products 7S Amended Theft (Expanded Coverage) AM Amended Failure to Match (Included A1 & A5 - Not Available A2 & A3) 7U Backup of Sewers, Drains or Sump Systems (Coverage A - Coverage C) $______________ 6K Blizzard Death Coverage - Livestock P Collapse - Due to Weight of Ice, Snow or Sleet 7W Expanded Collision and/or Overturn-Plus (Cov E or F) 7Y Expanded Collision and/or Overturn (Cov E or F) Z Coverage Adjustment Endorsement 6S Debris Removal $________________ 7X Expanded Vehicle Damage T Farm Extra Expense R Cab Glass (All Mobile Farm Equipment) Optional Deductible $_________________ 6P LivestockConfinementCoverage 6J ModifiedReplacementCost(CoverageA) (Agreed Percentage) 7B Non-Depreciation of Repairs (Coverage E or F) S Peak Season Inventory Farm Personal Property U Recreational Equipment J Replacement Cost Coverage (Buildings) K Replacement Cost Endorsement (Coverage C) 6R Scheduled Cab Glass (Coverage E or F) Optional Deductible $_________________

Yes/No x 7C Amended Vandalism or Malicious Mischief and Theft

(Expanded Coverage) 7D Amended Vandalism or Malicious Mischief (Expanded Coverage) 7A Collapse - Weight of Ice, Snow or Sleet (Coverage E or F) 7Q Collapse - Weight of Ice, Snow or Sleet (Coverage G) 6W Deferred Loss Payment 6X Deferred Loss Payment W Deferred Loss Payment X Deferred Loss Payment 7H Earthquake 7P Leased, Rented or Borrowed Farm Machinery, Vehicles and Equipment of Others (Coverage E) 7N Loss of Income (Coverage G) 7R Loss of Use or Income (Coverage G) 6T Loss of Income or Rent V Restriction of Individual Policies 7J Theft Coverage Extension (Construction Material & Supplies) (Coverage A or G)

CF-1000a (Ed. 4-13)

MAFMIC FORMS AVAILABLE

PREMIUM COMPUTATION FIRE WIND

Class Insurance Amount Rate Premium WIND PREMIUM

Class A-1

Personal Property

Add'l Living Expense

RATE PREMIUM

OPTIONAL COVERAGES: List and Describe

Total Ins. Amount

Total Wind Premium

Subtotal: Fire Premium Liability Premium

Total Fire Premium

Total Fire Premium Inland Marine

Total Policy Premium

WORKSHEETDWELLING REPLACEMENT COST ESTIMATE - Use the MS/B RCT software program and ATTACH THE RCT PRINTOUT.

CLASS G - FARM OUTBUILDINGS SCHEDULE

Total Cost Replace- Actual AmountLoc. Type of Type of Year Square Per Sub- Fixed ment Cash of Ins.No. Class Exterior Roofing Built L W H Feet Sq. Ft. total Equip. Cost Value Requested

Additional Information:

InteriorFrameworkWood/Steel/Pole/Block

BUILDINGUSE

AGE

Dimensions/Bushel Capacity

Conc

rete

Floo

r

Insu

late

d &

Cove

ring

Pit U

nder

Build

ing

Wire

dHe

ated

Type

of

Foun

datio

n