Fire Policy Number: RAM Mutual Insurance Company P.O. Box 308 Esko, MN 55733 TM41 3-09 AND Farm Partner Application Individual Partnership Corporation Other New Renewal of Policy #: Name: From: To: Address: (12:01 am at address of named insured) General Agency: Annual Semi-Annual Quarterly Phone #: Insured: Annual Monthly* RAM-Pay* Social Security #: *Requires minimum initial payment of 2 months) Perils/Policy Included: Fire Windstorm and Hail FCPL CPL Inland Marine* (Complete Supplemental Application) OL&T (Complete Separate Application) Deductible: $250 $500 $1,000 Included $2,500 $5,000 $10,000 $25,000 Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D Description of Premises: List all property owned, leased, rented, or maintained. Farm No. No. of Dwellings Sets of Buildings Acres Quarter Section Sec- tion Twp. Range Township Fire # County State Interest Owner or Tenant 1 2 3 4 UNDERWRITING GUIDE - Furnish photos of all buildings All questions must be answered or application may be returned. If asked to explain or list, please use the space provided, if more room is needed please list the question number, explanation, and attach a separate memo. 1. Date of last on-site inspection and by whom: 2. Principal farm operations are: Grain Dairy Livestock Poultry Occupation other than farming: 3. General housekeeping and condition of premises: Excellent Good Fair Poor - 1 -
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Farm Partner Application RAM Mutual Insurance CompanyTrampoline? Yes No F. Does applicant own dog(s)? Yes No #: Roadside stand? Yes No Breed(s): Business office or incidental sales?
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Fire Policy Number:
RAM Mutual Insurance CompanyP.O. Box 308
Esko, MN 55733
TM41 3-09
AND
Farm Partner Application
Individual Partnership Corporation Other New Renewal of Policy #:
Name: From: To:
Address: (12:01 am at address of named insured)
General Agency: Annual Semi-Annual Quarterly
Phone #: Insured: Annual Monthly* RAM-Pay*
Social Security #: *Requires minimum initial payment of 2 months)
Perils/Policy Included: Fire Windstorm and Hail FCPL CPL
Inland Marine* (Complete Supplemental Application) OL&T (Complete Separate Application)
Deductible: $250 $500 $1,000 Included $2,500 $5,000 $10,000 $25,000
Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D
Description of Premises: List all property owned, leased, rented, or maintained.
Farm No. No. of
Dwellings Sets of
Buildings Acres Quarter Section
Sec-tion Twp. Range Township Fire # County State
Interest Owner or Tenant
1
2
3
4
UNDERWRITING GUIDE - Furnish photos of all buildings All questions must be answered or application may be returned. If asked to explain or list, please use the space provided, if more room is needed please list the question number, explanation, and attach a separate memo.
1. Date of last on-site inspection and by whom:
2. Principal farm operations are: Grain Dairy Livestock Poultry Occupation other than farming:
3. General housekeeping and condition of premises: Excellent Good Fair Poor
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4. Dwelling:
A. Age of dwelling: G. Wood heating system: Yes No
B. Age of roof: Type: Central Space Fireplace
C. Age of wiring: # of Amps: Age in years:
D. Age of plumbing: H. Smoke Alarm(s): Yes No
E. Occupancy: I. Fire Extinguisher(s): Yes No
Owner Tenant Unoccupied J. Solar heating: Yes No If Yes, explain:
Vacant Seasonal Under Construction Other:
F. Central Heating: Yes :tnempiuqe gnitareneg dniW .K oN Yes No
Type:
Age of heating unit in years:
5. Outbuildings: If an answer to a question is Yes, list the building and please explain.
A. Occupied by: Owner Tenant Off-premises Tenant
B. Condition of buildings: Excellent Good Fair Poor
C. Any building not used for designed purpose? 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. Liability Survey:
A. Does the applicant have: D. Does the applicant own any livestock? Yes No
Seasonal property? Yes No E. Does the insured own horses? Yes No #:
Rental property? Yes No Away from premises? Yes No
Swimming pool? Yes No Does insured board other horses? Yes No #:
Trampoline? Yes No F. Does applicant own dog(s)? Yes No #:
Roadside stand? Yes No Breed(s):
Business office or incidental sales? Yes No
B. Does applicant do custom farming? Yes No G. Has the dog(s) ever bitten anyone? Yes No
Type: Shown aggressive behavior? Yes No
Custom spraying involved? Yes No H. In what condition are the applicant’s fences? Good Fair Poor
Gross annual custom farming receipts? I. Do all steps have adequate handrails? Yes No
C. Are premises used for any business or professional purposes
other than farming? Yes No If Yes, explain: J. Condition of farm equipment: Good Fair Poor
Has safety equipment been altered or removed? Yes No
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7. Other Insurance:
A. Is there other insurance? Yes No If Yes, with whom?
B. Is there other insurance with RAM? Yes No If Yes, policy number:
8. How long has agent personally known applicant?
Does agent personally recommend issuance of this policy? Yes No
9. Other information:
Special Restrictions:
Applicant’s Signature:
Loss History - List ALL losses, at this or any other location, within the last three (3) years or any loss ever if over $10,000.
List dates, type, and amount: None
PREVIOUS CARRIER (at this or prior location):
Was any policy cancelled, declined or non-renewed? Yes No
Explain:
Initials of Insured (REQUIRED):
GENERAL AGENTS USE ONLY
Application has been reviewed and approved. GA’s initials:
Agent
and
Address
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CODE AMOUNT DESCRIPTION Fire/Wind
CODE AMOUNT DESCRIPTION Fire/Wind
CLASS A-1 DWELLINGS - Photos Required Dwelling Replacement Cost and Coverage Adjustment is included
Class A-1 Basic Broad Special
Superior A-1 Special ______ _______ $ _____________________ Residence ______ _______ $ _____________________ Household Personal Property ______ _______ $ _____________________ Increase in Living Costs ______ _______ $ _____________________ ________________________ $ _____________________ Sub-Total
Protected Partially Protected Unprotected
OPTIONAL COVERAGES
Special Form Unscheduled Personal Property Replacement Cost - Household Personal Property
Policy provisions require individual scheduling of above items when not being used in Unscheduled Farm Personal Property. The following items may be optionally scheduled.
1. all property under Class E is listed to at least 80 percent of actual cash value.
2. Class F property is insured to 100 percent of the Inventory Schedule. The applicant understands that an 80 percent coinsurance requirement applies and agrees to, at all times, maintain contributing insurance on the property insured to the extent of at least 80 percent of its actual cash value, and failing to do so, shall to the extent of any deficit bear the proportion of any loss.
3. all Class G-1 structures are insured to at least 80 percent of replacement value.
4. all Class G-2 structures are insured to at least 50 percent 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. As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting departments of RAM Mutual and Palo 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 for subsequent amendments and renewals as long as the policy remains in force.
8. the check box “Yes/No” areas accurately indicate desired coverage.
9. 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. Loss History is correct. ________ 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.