COMBINATION PACKAGE POLICY HEADINGS DOCUMENT

Transcription

1 COMBINATION PACKAGE POLICY HEADINGS DOCUMENT BACK TO MAIN MENU TABLE OF CONTENTS ITEM NSCPP PAGE Additional Coverages NS-710 & NS-700 Declarations Print Statements Applies to NS Applies to NS-710 and NS Auto Companion Policy Discount FPL NS-710 Declarations Print Statements... 9 General Declaration Print Statements Optional Coverages AM Amended Failure to Match... 1 J Replacement Cost Coverage... 1 K Replacement Cost Endorsement... 1 L Total Loss Endorsement... 1 Q Added Perils for Refrigerated Food Products... 1 R Glass Coverage... 1 S Peak Season Inventory Farm Personal Property... 2 T Farm Extra Expense... 2 U Recreational Equipment J Modified Replacement Cost Coverage for Dwellings K Blizzard Death Coverage Livestock M Exclusion of Loss Due to By-Products From Production or Processing Products P Livestock Confinement Coverage R Scheduled Cab Glass S Debris Removal Coverage AI Additional Insured B Non-Depreciation of Repairs H Earthquake LF Limited Fungus, Bacteria, Wet Rot or Dry Rot Coverage N Loss of Income Endorsement P Leased, Rented or Borrowed Farm Machinery, Vehicles and Equipment Q Collapse Weight of Ice, Snow, or Sleet R Loss of Use or Income U Backup of Sewers, Drains or Sump Systems... 4 NS-42A Office, Professional, Private School or Studio Use... 4 NS-70 Add l Residential Premises Rented to Others... 4 NS-71 Business Activities... 5 GL-72 Additional Insureds (Resident of your Household)... 5 NS-75 Watercraft... 5 North Star Mutual Ins. Co

2 COMBINATION PACKAGE POLICY HEADINGS DOCUMENT TABLE OF CONTENTS CONTINUED ITEM NSCPP PAGE GL-90 Incidental Business Pursuits... 5 FL-108 Additional Insureds (used on NS-810 only)... 5 NS-157A Care Provided for Others Coverage... 6 NS-164 Recreational Motor Vehicle Liability... 6 Custom Farm Work (Used on NS-710 only)... 6 FL-313 Custom Farm Work (Used on NS-810 only)... 6 NS-315A Additional Insured... 6 NS-316A Additional Insured Partnership... 6 ML-416 Additional Insured Landlord... 7 NS-423 Fruit or Vegetable Picking by Public/Horse Boarding Operations... 7 NS-506A Corporation as Named Insured... 7 NS-507 Farmer s Medical Payments... 7 FL-872 Farm Employers Liability Coverage... 7 FL-904 Personal Injury and Advertising Injury Liability Coverage... 8 CF-1098 Loss of Income... 8 CF-1269 Additional Insured (used on NS-800 only)... 8 CF-1297 Delux Dwelling Plus Endorsement... 8 CF-1545 ACV Loss Settlement Wind or Hail Losses to Roofs... 8 FL-1638 Farm Pollution and Clean Up Coverage... 8 CF-1671 Property Damage Deductible Insurance... 8 CF-1672 Property Damage Deductible Insurance... 9 CF-2160 Underground Service Line Coverage... 9 NS-2786 Identity Fraud Expense... 9 Secured Partys Interest NS27A Secured Partys Interest NS28A North Star Mutual Ins. Co

3 COMBINATION PACKAGE POLICY HEADINGS DOCUMENT The following forms/endorsements require certain information to be shown on the Declarations page. Below and on the following pages you will find each form listed. The title of the form as it must appear on the Declarations page is shown on the line just below the form number. Then an example of how the information for the form should be typed is shown. Additional statements and any explanation or guidelines are also shown. AM AMENDED FAILURE TO MATCH AM NOTE: For North Star this AM is automatically included for A1 and A5 dwellings. The AM will show up under the Perils Insured/Optional Coverages column on the same line as the item description. J REPLACEMENT COST COVERAGE J NOTE: Need to make an entry on A2 dwellings to indicate item(s) this applies to. A1 & A5 dwellings will automatically have this. The J will show up under the Perils Insured/Optional Coverages column on the same line as the item description. K REPLACEMENT COST ENDORSEMENT K $50,000 PERSONAL PROPERTY COVERAGE C BROAD K REPLACEMENT COST PERSONAL PROPERTY NOTE: Personal Property limit needs to be entered. The statement Replacement Cost Personal Property will show below the line with the coverage amount, perils and the K for the personal property. L TOTAL LOSS ENDORSEMENT COVERAGE L NOTE: No additional information for this endorsement needed here. Q ADDED PERILS FOR REFRIGERATED FOOD PRODUCTS Q ADDED PERILS FOR REFRIGERATED FOOD PRODUCTS Total Coverage: $1,250 NOTE: Only shows up when the coverage for this is more than $250. The amount of coverage is entered in. The TP- 1 provides up to $250 coverage. R GLASS COVERAGE R NOTE: Need to make an entry to indicate item(s) this applies to. The R will show up under the Perils Insured/Optional Coverages column on the same line as the item description. North Star Mutual Ins. Co. GA-CPP-H

4 S PEAK SEASON INVENTORY FARM PERSONAL PROPERTY S PEAK SEASON INVENTORY FARM PERSONAL PROPERTY CORN OCTOBER 15 APRIL 15 40,000 NOTE: The type of farm personal property, the dates coverage is in effect, and the amount of coverage needs to be entered. The S will show up under the Perils Insured/Optional Coverages column on the same line as the item description. T FARM EXTRA EXPENSE T $3,000 FARM EXTRA EXPENSE NOTE: Limit needs to be entered. The T will show up under the Perils Insured/Optional Coverages column on the same line as the item description. U RECREATIONAL EQUIPMENT U $3, Polaris ATV, # U NOTE: LIMIT, DESCRIPTION and a U must be entered. Perils provided by U are Fire or Lightning, Windstorm or Hail, Vandalism and Malicious Mischief and Theft. 6J MODIFIED REPLACEMENT COST COVERAGE FOR DWELLINGS - 6J AGREED PERCENTAGE: 50%. NOTE: You would enter one of the following percents: 50%, 60%, 70% or 80%. 6K BLIZZARD DEATH COVERAGE LIVESTOCK 6K $10,000 BLIZZARD DEATH COVERAGE - LIVESTOCK NOTE: Limit needs to be entered when policy carries Unscheduled Farm Personal Property if this option is purchased. When livestock is scheduled simply show the 6K under the Perils Insured/Optional Coverage column. 6M EXCLUSION OF LOSS DUE TO BY-PRODUCTS FROM PRODUCTION OR PROCESSING PRODUCTS 6M By Location: FORM 6M APPLIES TO LOCATION #001 By Policy: FORM 6M APPLIES TO THIS POLICY NOTE: 6P LIVESTOCK CONFINEMENT COVERAGE 6P NOTE: The statement, 6P APPLIES would show below each building with this coverage. The Limit of Coverage must be shown for each building this coverage applies to. North Star Mutual Ins. Co. GA-CPP-H

5 6R SCHEDULED CAB GLASS 6R 2006 John Deere 4230 Tractor 2008 John Deere 9500 Combine NOTE: The ITEM(S) TO BE COVERED by 6R need to be described. If a deductible other than the policy deductible applies to 6R this needs to be entered and will show up under the Deductible Information. When this Optional Coverage applies a 6R will show in the Forms Section on the Declarations. 6S DEBRIS REMOVAL COVERAGE - 6S DEBRIS REMOVAL (MAXIMUM): $2,000 NOTE: The $2,000 amount will always be shown, unless a higher amount is purchased, in this case the higher amount would be shown. 7AI ADDITIONAL INSURED 7AI Location of Premises or Insured Item: SECTION , LYON COUNTY Name and Address of Person or Organization and Interest: JOHN SMITH, 1234 FIRST AVE., ANYTOWN, MN 55555, CO-OWNER NOTE: Location of Premises or Insured Item, and Name and Address of Persons or Organizations and Interest need to be entered. 7B NON-DEPRECIATION OF REPAIRS 7B NON-DEPRECIATION OF REPAIRS $25,000 NOTE: Limit needs to be entered. No additional information needed for this endorsement. 7H EARTHQUAKE 7H NOTE: No additional information for this endorsement is needed here. When this optional coverage applies the 7H + edition date will show in the Forms Section on the Declarations. This coverage is provided by the Township Mutual. 7LF LIMITED FUNGUS, BACTERIA, WET ROT, DRY ROT COVERAGE 7LF $5,000 LIMITED FUNGUS, BACTERIA, WET ROT, DRY ROT COVERAGE NOTE: The coverage shown on the Declarations is an annual aggregate limit. 7N LOSS OF INCOME ENDORSEMENT 7N $5,000 LOSS OF INCOME ENDORSEMENT NOTE: Limit needs to be entered. No additional information needed for this endorsement. North Star Mutual Ins. Co. GA-CPP-H

6 7P LEASED, RENTED OR BORROWED FARM MACHINERY, VEHICLES & EQUIPMENT 7P $2,000 BORROWED FARM MACHINERY NOTE: Limit needs to be entered. 7Q COLLAPSE WEIGHT OF ICE SNOW OR SLEET COVERAGE G 7Q NOTE: No additional information for this endorsement needed here. When this optional coverage applies the 7Q + edition date will show in the Forms Section on the Declarations. The 7Q will show up under the Perils Insured/Optional Coverages column on the same line as the description of the insured item this coverage applies to. This coverage is provided by the Township Mutual. 7R LOSS OF USE OR INCOME 7R $5,000 LOSS OF USE OR INCOME ENDORSEMENT NOTE: Limit needs to be entered. State the building to which this coverage applies. 7U BACKUP OF SEWERS, DRAINS OR SUMP SYSTEMS 7U BACKUP OF SEWERS, DRAINS OR SUMP SYSTEMS 7U $5,000 NOTE: This only needs to show on the Declarations for coverage over $1,000. A coverage amount needs to be entered. (The TP-1 indicates that the limit is $1,000 but if greater than $1,000 then the limit will show on the Declarations.) NS-42A OFFICE, PROFESSIONAL, PRIVATE SCHOOL OR STUDIO USE - NS-42A BEAUTY SHOP OPTIONAL STATEMENT THIS BUSINESS IS CONDUCTED ON THE FOLLOWING PREMISES: 231 FRONT ST., ANYTOWN, MN NOTE: If the business is conducted on other premises than the insured premises, the optional statement listed above would go on as well as the location. NS-70 ADD'L RESIDENTIAL PREMISES-RENTED TO OTHERS (LIAB. COV. ONLY) - NS-70 1 FAMILY DWELLING AT 1234 N. FIRST, ANYTOWN, MN FAMILY DWELLING AT 1237 N. FIRST, ANYTOWN, MN NOTE: Liability and Medical Payments for 1 to 4 family rental dwellings can be provided by this form and the above shows how the information would be listed. North Star Mutual Ins. Co. GA-CPP-H

7 NS-71 BUSINESS ACTIVITIES - NS-71 JOHN SMITH, HIGH SCHOOL TEACHER OPTIONAL STATEMENT COVERAGE FOR LIABILITY ARISING OUT OF CORPORAL PUNISHMENT IS INCLUDED. NOTE: Liability for corporal punishment is excluded by this form, however, if liability for corporal punishment is wanted then this optional statement would have to be shown. GL-72 ADDITIONAL INSUREDS (RESIDENT OF YOUR HOUSEHOLD) GL-72 NAME OF ADDITIONAL INSURED JOHN SMITH NOTE: Information in this endorsement needs to be entered NS-75 WATERCRAFT (LIABILITY COVERAGE ONLY) - NS-75 OUTBOARD MOTORS 1975 JOHNSON, 65 H.P., S# INBOARD/OUTBOARD BOATS 1985 LUND, 20 ft., 150 H.P., 33 MPH, S# PERSONAL WATERCRAFT KAWASAKI JET SKI S# NOTE: Standard CPP automatically includes coverage for outboard, inboard or inboard/outboard motors 50 HP or less. CPP "Delux Dwelling Plus" automatically includes coverage for outboard, inboard or inboard/outboard motors 100 HP or less. We do require a charge for all personal watercraft (wet bikes, jet skis, etc.) no matter what the horsepower is. GL-90 INCIDENTAL BUSINESS PURSUITS GL-90 NAME OF INSUREDS: JOHN SMITH AND FRED SMITH BUSINESS: REPAIR SHOP ESTIMATED RECEIPTS: $5,000 COVERAGE FOR PRODUCTS AND COMPLETED WORK IS EXCLUDED. NOTE: NAME OF INSUREDS, BUSINESS, and ESTIMATED RECEIPTS must be shown. One of the following optional statements must be shown: COVERAGE FOR PRODUCTS AND COMPLETED WORK IS INCLUDED or COVERAGE FOR PRODUCTS AND COMPLETED WORK IS EXCLUDED. FL-108 (USED ON NS-810 only) ADDITIONAL INSUREDS FL-108 JOHN SMITH, 1234 FIRST AVE., ANYTOWN, MN CO-OWNER OF SECTION , LYON COUNTY NOTE: The following information must be listed to match up with this endorsement. The three forms of interests are CO-OWNER OF THE INSURED PREMISES; CONTROLLING INTEREST; and MORTGAGEE, ASSIGNEE OR RECEIVER. North Star Mutual Ins. Co. GA-CPP-H

8 NS-157A CARE PROVIDED FOR OTHERS COVERAGE - NS-157A DESCRIPTION OF BUSINESS: BABYSITTING PERSONS RECEIVING CARE: 5 OR LESS COV L PER OCCURRENCE LIMIT: $300,000 COV L PER PERSON SUB-LIMIT: $100,000 NOTE: The description of business should always be Babysitting and the persons receiving care should always read: 5 or less. The per person limit will always be $100,000 and the per occurrence limit will be the same as the Coverage "L" limit. NS-164 RECREATIONAL MOTOR VEHICLE LIABILITY - LIABILITY COVERAGE ONLY NS-164 MAKE OR MODEL SERIAL OR MOTOR NUMBER POLARIS XLT S# NOTE: The information in this endorsement needs to be entered. (USED ON NS-710 only) CUSTOM FARM WORK ESTIMATED ANNUAL RECEIPTS: $5,000 DESCRIPTION: COMBINING NOTE: You would show the actual amount of receipts and describe the type of custom farm work. FL-313 (USED ON NS-810 only) CUSTOM FARM WORK FL-313 ESTIMATED RECEIPTS: $5,000 DESCRIPTION: COMBINING NOTE: You would show the actual amount of receipts and describe the type of custom farm work. NS-315A ADDITIONAL INSURED - NS-315A JOHN SMITH, 1234 FIRST AVE., ANYTOWN, MN CO-OWNER OF 160 ACRES AT NW 1/4 SECTION , LYON COUNTY. NOTE: The following information must be listed to match up with this endorsement: NAME AND ADDRESS OF ADDITIONAL INSURED, INTEREST AND LOCATION OF PREMISES. NS-316A ADDITIONAL INSURED - PARTNERSHIP - NS-316A JOHN SMITH FRED SMITH CARL SMITH OPTIONAL STATEMENT WITH RESPECT TO "FRED SMITH" THIS POLICY APPLIES ONLY TO THE FARMING OPERATIONS, ACTIVITIES AND PROPERTY. NO COVERAGE IS AFFORDED FOR THE NON-FARMING OPERATIONS, ACTIVITIES OR PROPERTY OF "FRED SMITH". NOTE: This optional statement would only be used when a partner has another policy providing personal liability. North Star Mutual Ins. Co. GA-CPP-H

9 ML-416 ADDITIONAL INSURED - LANDLORD - ML-416 JOHN SMITH, 1234 FIRST AVE., ANYTOWN, MN OWNER OF SECTION , LYON COUNTY. NOTE: The following information must be listed to match up with this endorsement: NAME, ADDRESS and INTEREST of the additional insured as well as the LOCATION OF THE INSURED PREMISES he/she has an interest in. NS-423 (USED ON NS-710 & NS-810) FRUIT OR VEGETABLE PICKING BY PUBLIC / HORSE BOARDING OPERATIONS NS-423 FRUIT OR VEGETABLE PICKING BY THE PUBLIC DESCRIPTION, LOCATION, ESTIMATED RECEIPTS STRAWBERRY PICKING; SECTION LYON COUNTY, MN; $3,000 HORSE BOARDING OPERATIONS DESCRIPTION, LOCATION, NO. OF HORSES HORSEBOARDING; SECTION LYON COUNTY, MN; 2 HORSES NOTE: The DESCRIPTION, LOCATION and ESTIMATED RECEIPTS must be shown for Fruit or Vegetable Picking. The DESCRIPTION, LOCATION and NUMBER OF HORSES must be shown for Horse Boarding Operations. Can have either Fruit or Vegetable Picking by Public or Horse Boarding Operations or both. For Fruit or Vegetable Picking the following optional statement would go on if such coverage applies: COVERAGE FOR LADDERS OR OFF GROUND PICKING IS INCLUDED. NS-506A CORPORATION AS NAMED INSURED - NS-506A JOHN SMITH FRED SMITH CARL SMITH OPTIONAL STATEMENT WITH RESPECT TO "FRED SMITH" THIS POLICY APPLIES ONLY TO THE FARMING OPERATIONS, ACTIVITIES AND PROPERTY. NO COVERAGE IS AFFORDED FOR THE NON-FARMING OPERATIONS, ACTIVITIES OR PROPERTY OF "FRED SMITH". NOTE: This optional statement for form NS-506A would only be used when a corporation member has another policy providing personal liability. NS-507 FARMER'S MEDICAL PAYMENTS - NS-507 LIMIT FOR EACH INSURED : $1,000 PERSONS INSURED: FRED SMITH - 11/52- INSURED SALLY SMITH - 8/56 - WIFE NOTE: The limit, name, birth date, and relationship must be entered. FL-872 (USED ON NS-810 only) FARM EMPLOYERS LIABILITY COVERAGE FL-872 COVERAGE V-FARM EMPLOYERS LIABILITY (EACH OCCURRENCE) $100,000 COVERAGE W-FARM EMPLOYEES MEDICAL PAYMENTS (EACH EMPLOYEE) $500 PART-TIME, WORKING 40 DAYS OR LESS PER YEAR-TOTAL NUMBER OF MAN-DAYS IS: 150 NOTE: Whichever type of employee they have determines which of the following optional statements is used: FULL TIME, WORKING 180 DAYS PER YEAR OR MORE: 1; PART TIME, WORKING OVER 40 DAYS BUT LESS THAN 180 DAYS PER YEAR: 1; PART TIME, WORKING 40 DAYS OR LESS PER YEAR TOTAL NUMBER OF MAN-DAYS IS: 150. Number of employees or man-days need to be entered. One, 2, or all 3 of the optional statements can be shown. North Star Mutual Ins. Co. GA-CPP-H

10 FL-904 (USED ON NS-810 only) PERSONAL INJURY AND ADVERTISING INJURY LIABILITY COVERAGE FL-904 PERSONAL INJURY & ADVERTISING INJURY COVERAGE (ANY 1 PERSON OR ORG.) $100,000 NOTE: Limit needs to be entered. Limit entered is determined by the limit purchased. CF-1098 LOSS OF INCOME (POULTRY BUILDINGS) CF-1098 $5,000 LOSS OF INCOME (POULTRY BUILDINGS) NOTE: Limit needs to be entered. CF-1269 (USED ON NS-800 only) ADDITIONAL INSURED CF-1269 JOHN SMITH, 1234 FIRST AVE., ANYTOWN, MN CO-OWNER OF 160 ACRES AT NW ¼ SECTION , LYON COUNTY. NOTE: The following information must be listed to match up with this endorsement: NAME AND ADDRESS OF PERSON OR ORGANIZATION, INTEREST AND LOCATION OF PREMISES. CF-1297 DELUX DWELLING PLUS ENDORSEMENT NOTE: This statement would be entered under the information pertaining to the dwelling this applies to. CF-1545 ACV LOSS SETTLEMENT WIND OR HAIL LOSSES TO ROOFS CF-1545 NOTE: This statement would be entered under the information pertaining to either the Primary Dwelling or the Secondary Dwelling, whichever it applies to. FL-1638 (USED ON NS-810 only) FARM POLLUTION AND CLEAN UP COVERAGE (LIMITED COVERAGE) FL-1638 DISCHARGE, DISPERSAL, SEEPAGE, MIGRATION, SPILL, RELEASE OR ESCAPE OF AGRICULTURAL CHEMICALS, LIQUIDS AND GASES AGGREGATE LIMIT IS: $50,000 DEDUCTIBLE PER OCCURRENCE IS: $1,000 NOTE: The Aggregate Limit for Farm Pollution And Clean Up Coverage (Limited Coverage) is a constant at $50,000. The deductible is a constant at $1,000. SPRAY DRIFT OF AGRICULTURAL CHEMICALS AGGREGATE LIMIT IS: $100,000 NOTE: The aggregate limit for Spray Drift Of Agricultural Chemicals is a constant at $100,000. When Farm Pollution And Clean Up Coverage (Limited Coverage) is purchased then Accidental Spray Drift of Agricultural Chemicals coverage is included for $100,000 (aggregate limit). CF-1671 (USED ON NS-710 only) PROPERTY DAMAGE DEDUCTIBLE INSURANCE CF-1671 AMOUNT OF DEDUCTIBLE (EACH OCCURRENCE): $500 NOTE: The deductible amount needs to be entered. The deductible can be either $500 or $1,000. North Star Mutual Ins. Co. GA-CPP-H

11 CF-1672 (USED ON NS-810 only) PROPERTY DAMAGE DEDUCTIBLE INSURANCE CF-1672 AMOUNT OF DEDUCTIBLE (EACH OCCURRENCE): $500 NOTE: The deductible amount needs to be entered. The deductible can be either $500 or $1,000. CF-2160 UNDERGROUND SERVICE LINE COVERAGE CF-2160 $10,000 Limit applies to Dwelling at Loc #01 (This will be the description of the dwelling to which this endorsement applies) Note: This statement will be entered under the information pertaining to the dwelling to which it applies. The $10,000 limit will apply per dwelling. NS-2786 IDENTITY FRAUD EXPENSE NS-2786 Identity Fraud Expense limit: $5,000 NOTE: $5,000 is automatically included and would be shown on all policies unless a higher limit is purchased, in which case you show the limit purchased. Other limits available are $10,000, $15,000, $20,000 & $25,000. North Star Mutual Ins. Co. GA-CPP-H

12 FPL NS710- DECLARATION PRINT STATEMENTS Below is a listing of additional headings that are used when Farm Personal Liability (NS-710) is applicable. DAMAGE TO PROPERTY OF OTHERS (LIABILITY COVERAGE ONLY) LIMIT OF COVERAGE (EACH OCCURRENCE) $1,000 NOTE: $1,000 is automatically included and would be shown on all policies unless higher limits are purchased in which case you show the limit purchased.($2,000; $3,000; $4,000; $5,000; $6,000; $7,000; $8,000; $9,000; or $10,000) FARM EMPLOYER'S LIABILITY PART TIME, WORKING 40 DAYS OR LESS PER YEAR. TOTAL NUMBER OF MAN-DAYS IS: 40 OR LESS FARM EMPLOYER'S LIABILITY PART TIME, WORKING OVER 40 DAYS BUT LESS THAN 180 DAYS PER YEAR. NUMBER OF PART TIME EMPLOYEES IS: 1 FARM EMPLOYER'S LIABILITY FULL TIME, WORKING 180 DAYS PER YEAR OR MORE. NUMBER OF FULL TIME EMPLOYEES IS: 1 NOTE: Part time, working 40 days or less per year would always be listed for farm employer's liability. This is automatically provided and should always read 40 or less. Part time, working over 40 days but less than 180 days per year or full time, working 180 days per year or more would only be listed when the insured has an employee that would be classified as such. The actual number of employees that work the number of days should be indicated. 1, 2 or all 3 of the farm employer's liability statements could be shown. DISCHARGE, DISPERSAL, SEEPAGE, MIGRATION, SPILL, RELEASE OR ESCAPE OF AGRICULTURAL CHEMICALS, LIQUIDS AND GASES AGGREGATE LIMIT IS: $50,000 DEDUCTIBLE PER OCCURRENCE IS: $1,000 NOTE: The aggregate limit is a constant at $50,000. The deductible is a constant at $1,000. SPRAY DRIFT OF AGRICULTURAL CHEMICALS AGGREGATE LIMIT IS: $100,000 NOTE: The aggregate limit is a constant at $100,000. ADDITIONAL COVERAGES NS-710 and NS-700 DECLARATION PRINT STATEMENTS Below is a listing of additional headings that we use. Coverage for some of these headings are provided for in the Farm Personal Liability and Personal Liability Coverage Forms (we do not reference a form number in this case). The other headings that are shown with a form number are the titles of those forms. APPLY TO FARM PERSONAL LIABILITY (NS-710) ADDITIONAL FARM PREMISES WITH BUILDINGS SW 1/4, SEC , HUBBARD TWP., HUBBARD CO., MN NOTE: The above location is used as an example. You would show the correct location. North Star Mutual Ins. Co. GA-CPP-H

13 LIVESTOCK LIABILITY EXPOSURE CHARGE HORSE LIABILITY EXPOSURE INSURED HAS 6 HORSE(S) NOTE: 6 is used only as an example. You would show the actual number of horse(s). ANIMAL COLLISION FL-553 Limit: $400 Per Head NOTE: The limit per head needs to be shown. Two limits are available - $400 and $1,000 APPLY TO FARM PERSONAL LIABILITY (NS-710) AND PERSONAL LIABILITY (NS-700) ADDITIONAL RESIDENCE PREMISES MAINTAINED SEC , LONG ISLAND TWP, LYON CO., MN NOTE: The above location is used as an example. You would show the correct location. RESIDENCE EMPLOYEE RECREATIONAL MOTOR VEHICLE LIABILITY - NS-704 PERSONAL INJURY - NS-46 WATERBED LIABILITY - NS-209 GOLF CART LIABILITY COVERAGE - NS-432 Below is a listing of additional headings that are used on the CPP. SECURED PARTYS INTEREST NS27A SECURED PARTYS INTEREST NS28A Auto Companion Policy Discount: 5% Auto Policy Number is: NOTE: When this discount applies the percentage is always 5% and only applies if North Star Mutual insures the main residence of he Named Insured and North Star Mutual writes the primary Named Insured s Automobile policy. The Named Insured s must be the same on the CPP as on the Automobile policy. This statement would generally show up just below where the forms are listed out. North Star Mutual Ins. Co. GA-CPP-H

14 10% New/Upgraded Home Component Discount Applies. NOTE: When this discount applies you should show the actual percentage that applies based on the age of the electrical system. This statement shows up under the dwelling it applies to. New/Upgraded Home Component Discount only applies to A1 (Delux Dwelling) and A5 (Delux Dwelling Plus). SUPER STAR CREDIT APPLIES NOTE: The above statement would generally show up just below where the forms are listed out. GENERAL DECLARATION PRINT STATEMENTS The following paragraph(s) should appear on all new, revision, or renewal certificate policy declarations: ***PLEASE RETAIN THIS RENEWAL CERTIFICATE WITH YOUR ORIGINAL POLICY!! *** (NOTE: only put the above statement on Renewal Certificates) THIS DECLARATIONS REPLACES ALL PRIOR DECLARATIONS, IF ANY. IN RETURN FOR THE PAYMENT OF PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY DURING THE POLICY PERIOD SHOWN ABOVE. YOUR POLICY IS SUBJECT TO THE FORMS LISTED BELOW. IF THIS IS A RENEWAL CERTIFICATE OR A REVISION, ONLY THE NEW OR REVISED FORMS ARE ATTACHED. CURRENT POLICY FORMS ARE AVAILABLE ON REQUEST. The following wording should be used on all new policy decs and is shown just before the forms are listed: SUBJECT TO THE FOLLOWING FORMS AND OPTIONAL COVERAGES: The following wording should be used on all renewal certificate and revision policy decs and is shown just before the forms are listed: SUBJECT TO THE FOLLOWING FORMS AND OPTIONAL COVERAGES - ANY NEW OR REVISED FORM/OPTIONAL COVERAGE IS ATTACHED AND IS NOW A PART OF YOUR POLICY. CURRENT POLICY FORMS ARE AVAILABLE ON REQUEST. IF OPTIONAL COVERAGE J IS ON THE POLICY ONE OF THE FOLLOWING STATEMENTS SHOULD BE ON THE RENEWAL CERTIFICATE DECLARATIONS (or something very similar): THE LIMITS OF INSURANCE FOR BUILDINGS WITH COVERAGE J (AND IN SOME INSTANCES PERSONAL PROPERTY AND ADDITIONAL LIVING EXPENSE) HAVE BEEN AUTOMATICALLY UPDATED BASED ON CURRENT CONSTRUCTION FACTORS SUPPLIED TO US BY AN ACCREDITED APPRAISAL FIRM. THE PRESENT LIMITS OF INSURANCE ARE AS SHOWN ABOVE. THE "DELUX DWELLING PLUS" COVERAGES, DELUX DWELLING COVERAGES AND THE G-1 OUTBUILDINGS COVERAGES (IF LISTED ON THE DECLARATIONS) HAVE BEEN AUTOMATICALLY UPDATED BASED ON CURRENT CONSTRUCTION FACTORS SUPPLIED TO US BY AN ACCREDITED APPRAISAL FIRM. THE PRESENT LIMITS OF INSURANCE ARE AS SHOWN ABOVE. North Star Mutual Ins. Co. GA-CPP-H