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Page 1: 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?

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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Page 2: 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?

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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Page 3: 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?

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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Page 4: 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?

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

CLASS A-2 DWELLINGS - Photos Required

Limited Basic Broad ______ _______ $ ______________ Dwelling ______ ______x____x______ ______ _______ $ ______________ Household Personal Property ______ _______ $ ______________ Increase in Living Costs ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total

CLASS A-3 MOBILE HOMES - Photos Required

Limited Basic Broad ______ _______ $ _________ Home (Age/Make) ________ ______x____x______ ______ _______ $ _________ _____________________ ______x____x_____ ______ _______ $ _________ Additions ____________ ______x____x______ ______ _______ $ _________ Household Personal Property ______ _______ $ _________ Increase in Living Costs ______ _______ $ _________ _____________________ ______x____x______ $ _________ Sub-Total

CLASS E SCHEDULED FARM PERSONAL PROPERTY Includes 7B Non-depreciation of Repairs

Limited Basic Broad

______ _______ $ ________ Scheduled Farm Personal Property (From 7 on pg. 7) ______ _______ $ ________ Portable Crop or Grain Dryer (515) ______ _______ $ ________ Farm Operations Record Expenses (533) ______ _______ $ ________ ______________________________________ $ _________ Sub-Total

CLASS F UNSCHEDULED FARM PERSONAL PROPERTY Includes 7B Non-depreciation of Repairs

Limited Basic Broad Special

Code ________ _________ $ ___________________ Unscheduled Farm Personal Property (From 8 on pg. 7)

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Page 5: 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?

CLASS G-1 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required

Superior - Minimum of 80% of Replacement Cost Replacement Cost, Special Form, Opt. Cov. P,

& Coverage Adjustment Incl. $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______

G-1S (Asphalt Shingles)

$ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ Sub-Total

CLASS G-2 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required

(Includes Opt.Cov. P) Minimum of 50% of Replacement Cost

Above Average - ACV basis

Limited Basic $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ Sub-Total

CLASS G-3 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required

Minimum of 25% of Replacement Cost Standard - ACV basis

Limited Basic $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ _________________ ______x____x______ $ ______________ Sub-Total

CLASS H SPECIAL HAZARDS - Photos Required

Limited Basic ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total

- 5 -

Page 6: 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?

MISCELLANEOUS PROPERTY ACORD Form Required on All Commercial Property Check company manual for rules and binding authority.

Code ______ _______ $ ______________ _____________ ______x____x______

Code ______ _______ $ ______________ _____________ ______x____x______

Code ______ _______ $ ______________ _____________ ______x____x_____

$ ______________ Sub-Total

SEGAREVOC LANOITPO )ylnO egarevoC MT( SEGAREVOC LANOITPO

______ ______ Yes No $____________ Add’l Fire Dept. Service ______ ______ Yes No $____________ Peak Season - Item:

______ ______ Yes No $____________ Submersible Pumps

From: To:

______ ______ Yes No $____________ Underground Wiring ______ ______ Yes No $____________ Loss of Income

(Dairy & Hogs)

______ ______ Yes No $____________ Theft Coverage Extension ______ ______ Yes No $____________ Farm Extra Expense

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Blizzard Death

(Livestock) (RAM)

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $_________ Livestock Confinement (RAM)

(Separate RAM application required)

DO NOT BIND

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Special Form -

Farm Machine (RAM)

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Leased, Rented, or

Borrowed Farm Machinery Coverage

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Equipment Breakdown TM114

______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ _____________________

______ ______ Yes No $____________ _____________________

______ ______ Yes No $____________ _____________________

$ ______________ Sub-Total $ ______________ Sub-Total

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Class

Page 7: 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?

FARM PERSONAL PROPERTY INVENTORY SCHEDULED FARM PERSONAL PROPERTY UNSCHEDULED FARM PERSONAL PROPERTY

TOTAL SCHEDULED VALUE TOTAL UNSCHEDULED VALUE

(Add 1 through 6 - transfer amount to page 2) $____________ (Add 1 through 5 - transfer amount to page 2) $___________

Comments: _______________________________________________________________________

Policy provisions require individual scheduling of above items when not being used in Unscheduled Farm Personal Property. The following items may be optionally scheduled.

Item (Describe) Value

TRACTORS (505) No. 1 _________________ $ _________ No. 2 _________________ $ _________ No. 3 _________________ $ _________ No. 4 _________________ $ _________ Garden Tractor _________ $ _________ Skid Loader ___________ $ _________ _____________________ $ _________ Combine No. 1 (505) ____ $ _________ Combine No. 2 (505) ____ $ _________ Combine Heads ________ $ _________ Swather ______________ $ _________ Picker/Sheller (505) _____ $ _________ Other Self-propelled (505) $ _________ _____________________ $ _________ _____________________ $ _________ Port. Elevator __________ $ _________ Port. Auger No. 1 (505) __ $ _________ _____________________ $ _________ Port Auger No. 2 (505) ___ $ _________ _____________________ $ _________ Bale Racks & Trailers ____ $ _________ Beet Defoliators ________ $ _________ Beet Lifters ____________ $ _________ 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 ___________ $ _________ Hay Stacker/Loader _____ $ _________ Hay Stack Mover _______ $ _________ Livestock Trailer (Unlicensed)$ _________ Mach. Trailer (Unlicensed) __ $ _________ Manure Spreader _______ $ _________

LIVESTOCK Number Value Total

CATTLE (514) Dairy Cows ______ @ ______ $ _________ Heifers ______ @ ______ $ _________ Calves ______ @ ______ $ _________ Feeder Cattle ______ @ ______ $ _________ Stock Cattle ______ @ ______ $ _________ Bulls ______ @ ______ $ _________ Registered Cattle ______ @ ______ $ _________

SHEEP (514) Ewes ______ @ ______ $ _________ Rams ______ @ ______ $ _________ Lambs ______ @ ______ $ _________

HOGS (514) Sows ______ @ ______ $ _________ Boars ______ @ ______ $ _________ Feeder Pigs ______ @ ______ $ _________

HORSES (514) ______ @ ______ $ _________

TOTAL LIVESTOCK ………………… $ _________

POULTRY Hens (514) ______ @ ______ $ _________ Fryers ______ @ ______ $ _________

TOTAL POULTRY …………………… $ _________

HAY, STRAW, & FODDER Hay (522) ______ @ ______ $ _________ Straw ______ @ ______ $ _________ Fodder/Silage ______ @ ______ $ _________

TOTAL HAY, STRAW, & FODDER: $ _________

GRAIN, FEED, & SUPPLIESCorn (521) ______ @ ______ $ _________

Soybeans ______ @ ______ $ _________ Wheat ______ @ ______ $ _________ Oats ______ @ ______ $ _________ Sunflowers ______ @ ______ $ _________ Farm Chemicals ______ @ ______ $ _________ Veterinary Supplies ______ @ ______ $ _________ Fuel Oil & Grease ______ @ ______ $ _________ Paints ______ @ ______ $ _________ Commercial Feed ______ @ ______ $ _________ Ground Feed ______ @ ______ $ _________ _____________ ______ @ ______ $ _________

TOTAL GRAIN, FEED, & SUPPLIES $ _________

Item (Describe) Value

Mower _____________ $ ________ Plows _____________ $ ________ Potato Digger _______ $ ________ Rakes _____________ $ ________ Rotary Tiller/Hoe _____ $ ________ Row Cultivator _______ $ ________ Silage Wagon _______ $ ________ Silage Cutter/Blower __ $ ________ Stalk Cutter _________ $ ________ Snow Blower ________ $ ________ Spraying Tank _______ $ ________ Tractor Loader ______ $ ________ Vaculator ___________ $ ________ Other Farm Mach.(505)$ ________ __________________ $ ________ __________________ $ ________ __________________ $ ________

TOOLS & MISCEQUIPMENT (506)

Electric Motors ______ $ ________ Fuel Tanks _________ $ ________ Port. Generator ______ $ ________ Spare Parts _________ $ ________ Power Tools ________ $ ________ Hand Tools _________ $ ________ Welder _____________ $ ________ Compressor ________ $ ________ Bldg/Fencing Material _ $ ________ __________________ $ ________ __________________ $ ________

TOTAL FARM MACHINERY & EQUIP. $ ________

1

2

3

4

5

INSTALLED EQUIPMENT (591)

(Must be scheduled to be insured)

Bulk Tank/Cooler $ ________ Crop or Grain Dryer $ ________ Milk House Equip. $ ________ Milking Machine (Port)$ ________ Hog House Equip. $ ________ Poultry Equipment $ ________ Silo Unloader $ ________

TOTAL INSTALLED EQUIPMENT $ ________ 6

8 7

-7-

FARM MACHINERY & EQUIPMENT

Page 8: 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?

SCHEDULE OF ANNUAL LIABILITY RATES

COVERAGE APPLIES?

Yes No

CODE # DESCRIPTION PERSONAL LIABILITY

50,000 100,000 300,000 500,000 1,000,000

MEDICAL PAY

Add’l for each

$1,000 (max

$5,000)

PREMIUM

FCPL-1A Farmers CPL (FCPL)

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Additional Acreage Charge

sercA 000,1 ot 123 6109

9017 Over 1,000 Acres

Additional Acreage Charge

sercA mraF-noN 08 - 14 5109

L9105 Additional Named Insured - Premises Only Liability

L9106 Additional Named Insured - Personal Liability

CF108 Additional Residence Premises - Rented to Others

One Family

Two Family

CF109 Additional Residence Premises

9225 Additional Set of Buildings

CF71 Business Activities

L9186 Custom Farming: Rates per $100 of receipts Apply only if receipts exceed $1,000; rate then applies to all receipts

L9996 Damage to Property of Others (Coverage N) $1,000 included in policy Max Limit $10,000 - each additional $1,000 is $10

L9300 Employers’ Liability If payroll is between $8,000 and the amount required by MN Comp Law for Work Comp

L6123 Family Med. Pay Ages 12-65 only ($100 Deductible)

9023 Inactive Farmer Credit - N/A with CPL

9024 Hobby Farm Credit - N/A with CPL

Horse Exposure Charge

9231 □ 1-2 Horses 9232 □ 3-5 Horses 9233 □ 6-10 Horses

9235 Limited Non-Owned Horse Exposure 1-10 Horses. Rate applies to each horse.

9020 Livestock Exposure Charge

CF107 Office, Professional, Private School, or Studio Use

CF106 Personal Injury (No Medical)

L9125 Property in Control of Insured (Fire Legal Liability - Farm Premium) $10,000 included in policy. Each add’l $5,000 is $2.

CF105 Recreational Vehicles (Off Premises) (Fully Earned)

CF110 Watercraft Liability (Motors Over 100 HP)

CF110J Jet-Driven Watercraft

L9002 Trampoline

L9003 Wind Generator

- 8 -

Page 9: 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?

AGREEMENT AND SIGNATURE OF APPLICANT AND AGENT

The signatures below certify that:

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.

AGENT’S SIGNATURE: ______________________________________ DATE: __________________

- 9 -

Page 10: 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?

WORKSHEETPREMIUM COMPUTATION FIRE

Class Insurance Amount Rate Premium Premium Premium Total

egakcaP ecnediseR 1-A/1-AS

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stsoC gniviL ni esaercnI

WIND

FIRE WIND

Class Insurance Amount Rate Premium Premium Premium Total

OPTIONAL COVERAGES: List and Describe

Total Insurance Coverage Total Wind Premium

Total Fire Premium Wind Zone Adj.

Liability Premium

Total Fire Premium

Farm Partner Plus 5% max (Member Company Only) Inland Marine

Continuous Coverage Credit (5%) max Credits/Surcharges

Total Policy IRPM % Surcharge

Yes No

Q Added Perils for Refrigerated Food Products (TM Only)

6J Agreed Percentage Replacement Cost for Dwellings

7S Amended Theft

6R Cab Glass - Scheduled

7A Collapse - Weight of Ice, Snow, or Sleet

7Q Collapse - Weight of Ice, Snow, or Sleet

7W Collision and/or Overturn

7Y Collision and/or Overturn

6S Debris Removal

W Deferred Loss Payment

R Glass Coverage - Unscheduled $ Ded.

T Farm Extra Expense

7X Expanded Vehicle Damage

7H Earthquake

X Deferred Loss Payment

X

Yes No

SPC Special Package of Coverages - RAM (included)

SPC Special Package of Coverages - TM

7P Leased, Rented, or Borrowed Farm Machinery, Vehicles

& Equipment of Others

6T Loss of Income or Rent

7N Loss of Income

7R Loss of Use or Income

S Peak Season Inventory

K Replacement Cost Endorsement - Household

Personal Property

7U Backup of Sewers, Drains, or Sump Systems

7J Theft Coverage Extension

V Restriction of Individual Policies

Y Replacement Cost Provision

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