FARM AND RANCH APPLICATION

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Harold Parrish
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1 FARM AND RANCH APPLICATION Date: Agency: Status - (circle one): Quote Renewal Expiring Policy Number: Effective Dates: to APPLICANT INFORMATION Named Insured: Insured s Mailing Address: Insured s Phone Number(s): of Business Organization (circle one): Individual Joint Venture LLC Partnership Basic Organization - Other Years in business: Attach 3 years of prior carrier and loss history information -or - if in business less than 3 years provide short narrative about insured s working background UNDERWRITING INFORMATION Farm/ Ranch Operations Include: Yes No Controlled/Prescribed burn exposures? If yes, number of burns annually? Yes No Wildfire mitigation (vegetation control) is ongoing within 150 ft. of insured structures Yes No Has retail agent personally inspected the property? Date Visited: Yes No Any exposures or operations covered elsewhere? Subsidiary companies not covered elsewhere, or service on any board by insured? If yes explain: Page 1 of 15

2 PROHIBITED EXPOSURES: Aircraft or Aircraft Related Facilities Amusement Exposures: amusement rides, bounces, inflatables, trampolines, water slides Animals Exposures: Dogs, but only if breeding or ownership of Pit Bulls, German Shepherds, Huskies, Mastiffs, Rottweilers Exotic Animals, but only if inherently vicious (alpacas, bison, deer, llamas or similar acceptable) Racing Breeding, boarding, training or ownership Stabling, but only if third party animals stabled for a fee Training of Animals if third party is part of exposure (example: riding lessons/ training with owner) Petting Zoos and Zoos Artificial Insemination, but only if third party animals. Semen sales, but only if from specific or prize animals ATV s or Snowmobiles, but only if recreational use, off-premises use, third party use, or three wheeled-trike type Aquaculture, but only if ocean marine exposures Beaches, Lakes or Ponds, but only if third parties charged a fee and/or third party swimming allowed. Must be posted No Swimming if area is readily accessed by the general public. Boats/Watercraft over 26 feet long and/or with motors exceeding 50 hp Carriage or Sleigh Rides, but hay rides under 5 mph with no public road exposure are acceptable Caves, Mines, Open Pits, Quarries, Strip Mining Controlled/Prescribed Burns Controlled burns require following all applicable permit and fire department notification requirements Custom Farming including bale chasing, crop dusting, herbicide/pesticide work, silage pile work. If insured s operations are 100% custom farming that is also prohibited. Dams or Levees, but low height retention ponds used for watering animals acceptable Drying Facilities for grain or similar Dude Ranches, but only if guest participation in actual farm/ranch operations Dumps, Landfills Energy Related Facilities such as Ethanol, Mining, Oil and Gas, Wind with exception for Oil & Gas wells, or Wind Generation facilities that are owned, maintained and operated by independent third parties. These third parties must provide insured with evidence of liability coverage, and extend additional insured status to insured Feedlots / Stockyards / Containment Operations / Yard Containment Operations if more than 300 head in confined areas with no natural grazing. Up to 500 head acceptable west of the Mississippi River including IL & WI. Fencing must be regularly inspected and repaired. Fencing must be appropriate for animal types. Grain Elevators/Storage Bins, but only if they require active dust control systems Grain Milling, but only if for third parties for a fee Haunted Houses or Haunted Forests Hazardous Materials Application, Handing, or Storage, but only if for third parties for a fee Hot Springs Manure/Methane Digesters Mines, Open Pits or Quarries Non-Pasteurized Dairy or Juice Products sold directly to consumers Racing or Competitions with Motorized Equipment or Vehicles including but not limited to ATV s, autos, dirt bikes, motorcycles, snowmobiles, tractors, trucks or other types of motorized farm machinery or equipment Recreation Activities Third Parties: hang gliding, hot air ballooning if takeoff or landing is on insured s property, ice skating, paint ball, parachuting, rafting, rock climbing, water skiing, zip lines Rental of Machinery or Equipment, but only if to third parties for a fee Repair, Build or Design of Machinery, Equipment, Systems or Vehicles, but only if for third parties for a fee Rifle, Pistol or Skeet Ranges Rooftop Farming Sleigh Rides Page 2 of 15

3 PROHIBITED EXPOSURES (continued): Smoking of Meat, Seafood, Chicken if within 50 feet of insured structures or adjacent third party structures Stoves (coal, pellet or wood), but only if installation not done to code or to manufacturer s specifications (when no local building codes apply). Space heaters & portable kerosene heaters used as primary heat sources prohibited. Swimming Pools with platforms or slides. Diving boards up to 3 ft high acceptable. Tenants, but only if not insured and/or who have operations we would not normally insure on a primary basis Tobacco Farms Towers Owned by Insured, but only if over 72 feet high. Towers/Wind Turbines over 72 feet high only acceptable if facilities are owned, maintained and operated by independent third parties. These third parties must provide insured with evidence of liability coverage, and extend additional insured status to insured. Tractor Pulls Trails (ATV, dirt bike, horse, motorcycle, skiing, snowmobile) used by third parties. Hiking trails acceptable. LOCATION INFORMATION Page 3 of 15

4 LOCATION INFORMATION (continued) Page 4 of 15

5 FARM PROPERTY COVERAGE A DWELLINGS FARM PROPERTY COVERAGE B OTHER PRIVATE STRUCTURES APPURTENANT TO DWELLINGS FARM PROPERTY COVERAGE C HOUSEHOLD PERSONAL PROPERTY FARM PROPERTY COVERAGE D LOSS OF USE CAUSE OF LOSS VALUATION COV. A and B VALUATION COV. C Basic ACV ACV Broad RC RC Special Cov B Up to 10% of Coverage A limit provided at no additional premium, charge for limits above the 10% Cov C Up to 50% of Coverage A limit provided at no additional premium, charge for limits above the 50% Cov D Up to 20% of Coverage A limit provided at no additional premium, charge for limits above the 20% LOC # - BLDG # COVERAGE LIMIT A Dwelling Check if mobile home B Personal Use Structures - C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use - A - Dwelling Check if mobile home B Personal Use Structures C Household Personal Property D Personal Property Loss of Use (Copy this page if you need to list additional locations) Page 5 of 15

6 COVERAGE E SCHEDULED FARM PERSONAL PROPERTY CAUSES OF LOSS Basic Broad VALUATION is: ACV at time of loss RC subject to policy conditions # ITEM LIMIT OF INSURANCE 1 Grain, beans, Ground feed, Livestock feed, Silage, Threshed seeds - In buildings, structures, sacks, trucks or wagons only 2 Grain in stacks, shocks, swathes or piles In the open only 3 Hay, Fodder, and/or Straw In buildings or structures only Maximum available limit is 25,000 4 Hay, Fodder in stacks, windrows or bales and/or Straw In the open only Maximum available limit is 10,000 5 Computers & Related Software Use must include Farm, Ranch and/or Business Activities/Pursuits Personal use only to be declared under Coverage C instead TOTAL OF ITEMS 1 THRU 5 (Needed for rating purposes) # ITEM LIMIT OF INSURANCE 6 Farm Products, Materials, Supplies But not hay, grain, feed, fodder, silage, seeds, straw (see # 1 & 2) 7 Misc. Equipment Valued at 1000 Per Item or Less Machinery, Supplies, Tools or Vehicles usual or incidental to farm operations Declare as one blanket limit Off-premises coverage only available if you schedule items individually under # 12 below 8 Rented/Borrowed - Equipment, Machinery and/or Farm Vehicles Declare all values, even if no written contract Declare as one blanket limit 9 Trays, Boxes, Box shook (i.e. unassembled wood crates) 10 Farm Machinery, Equipment or Vehicles Valued over 1000 per Item Items MUST be scheduled here if you need off- premises coverage. Individual items are limited to the declared limit for that item Year Description Make Model Continue scheduling # 10 items on next page if needed Limit of Insurance on a per item basis Page 6 of 15

7 COVERAGE E SCHEDULED FARM PERSONAL PROPERTY (continued) 10 Farm Machinery, Equipment or Vehicles Valued over 1000 per Item (continued) Items MUST be scheduled here if you need off- premises coverage. Individual items are subject to declared limit for that item Year Description Make - Model Limit of Insurance on a per item basis TOTAL OF ITEMS 6 THRU 10 (Needed for rating purposes) (Copy this page if you need to list additional locations) Page 7 of 15

8 COVERAGE E SCHEDULED FARM PERSONAL PROPERTY (continued) Property coverage for Bees, Fish, Livestock or Worms does not include disease or mysterious disappearance # ITEM LIMIT OF INSURANCE 11 Livestock - Actual Death/Destruction Covers property loss due to collision if animal Is killed Eligible: Cattle, donkeys, goats, horses, mules, sheep, swine, and exotics (alpaca, bison, deer, llamas, yaks Describe unlisted exotic animal type here: Prohibited: Property coverage for birds (including poultry) 12 Livestock - Actual Death/Destruction Collision Only Covers property loss due to collision if animal Is killed Eligible: Cattle, donkeys, goats, horses, mules, sheep, swine, and exotics (alpaca, bison, deer, llamas, yaks Describe unlisted exotic animal type here: Prohibited: Property coverage for birds (including poultry) 13 Bees (Blanket Value) Actual Death or Destruction 15 Fish (Blanket Value) Actual Death or Destruction Only fish being raised for food consumption are eligible for property coverage 15 Worms (Blanket Value) Actual Death or Destruction # ITEM LIMIT OF INSURANCE 16 Check box if you want Equipment Breakdown coveraage Per form U Misc. (describe): 18 Misc. (describe): 19 Misc. (describe): 20 Misc. (describe): Page 8 of 15

9 COVERAGE F UNSCHEDULED FARM PERSONAL PROPERTY CAUSES OF LOSS Basic Broad VALUATION ACV at time of loss RC subject to policy conditions LIMIT: 5,000 COVERAGE G - BARNS, OUTBUILDINGS AND OTHER FARM STRUCTURES CAUSES OF LOSS Basic Broad VALUATION ACV at time of loss RC subject to policy conditions LOC # - COVERAGE G - DESCRIPTION, CONSTRUCTION, OCCUPANCY LIMIT OF INSURANCE BLDG # TOTAL OF COVERAGE G ITEMS (Needed for rating purposes) Page 9 of 15

10 OPTIONAL PROPERTY COVERAGE(S) LIMIT OF INSURANCE (Check only those that apply) Beekeepers Equipment Endorsement U616 Per U616 Disruption of Farming Operations - FP 0530 Equipment Breakdown - FP 0409 Increased Special Limits on Business Property - On Premises - FP % of on-premises limit will apply to off-premises exposures Per limits on FP0409 Loss Payable Provisions FP1211 Milk Contamination U614 Per U614 Motorized Golf Carts - FP 0527 Theft Exclusion Property Coverage E, F and G NA Page 10 of 15

11 FARM LIABILITY HIGHER LIMITS GL LIMITS Not available GENERAL AGGREGATE LIMIT Indicate your limit (Maximum limit is 2,000,000) S EACH OCCURRENCE LIMIT Indicate your limit - (Maximum limit is 1,000,000) PERSONAL AND ADVERTISING LIABILITY ANY ONE PERSON OR ORGANIZATION LIMIT Maximum limit is 1,000,000 FIRE DAMAGE LIMIT ANY ONE FIRE (PREMISES RENTED TO INSURED) Limit can not be deleted, increased or decreased MEDICAL PAYMENTS ANY ONE PERSON LIMIT (EXCEPT RESIDENT EMPLOYEES) Limit can not be deleted, increased or decreased Same as Each Occurrence Limit Indicated Above 50,000 1,000 EXCLUDED: Injury (BI, PD, AI/PI) to any temporary workers, volunteer workers, casual workers, independent contractors, or farm employee of an independent contractor FARM LIABILITY OPTIONS: (check only those that apply) Minimum per occurrence deductible is 500, indicate if higher: U696 Identity Recovery Coverage U614 - Milk Contamination - 10,000 limit U634 Products / Completed Operations Exclusion Liquor Legal Liability (available for vineyard/winery risks only. Limits provided are within the Farm Liability Limits stated above. Not available in: AK, AL, CT, DC, DE, HI, IA, IL, IN, MA, MD, ME, MI, MN, MO, NH, NJ, NY, OH,PA, RI, VA, VT, WV annual receipts for liquor served on or off vineyard premises Employees serving alcohol have liquor training such as TIPS or TOPS AQUACULTURE RISKS (check only those that apply): Certified by the Aquaculture Certification Council (ACC) Chemical and drug handling - always done to manufacturers specifications Licensing all required Federal, State and/or al licensing permits are on file. Recalls production and sales documentation is sufficient to allow quick recall of product Testing of product is per all applicable USDA standards Waste and sediment handling is done as required by all applicable environmental standards Page 11 of 15

12 FARM LIABILITY INFORMATION REQUIRED FOR PRICING CALCULATIONS FR01518 or FR01618 LAND Required rating for all Farm/Ranch risks All owned, leased or vacant land, regardless if used or vacant land 1 sq. mile = 640 acres Code FR01518 applies only to risks of 50 total acres or less Total Acres FR56760 AQUACULTURE FR01901 CROPS, PLANTS, NUTS, SOD, TREES, VINEYARDS, ETC. Acreage used for Beekeeping, berries, crops, field or forage crops, flowers, fruits, grain, herbs, honey, legumes, mushrooms, nursery stock, nuts, plants, spices, sod, straw, trees, vegetables, vineyards. Do NOT include acreage devoted solely to the raising of animals. FRO1391 LIVESTOCK Number of head of cattle, donkeys, goats, horses, mules, sheep, swine and exotics (alpaca, bison, deer, llamas, yaks). Do NOT include birds/poultry, or animals being raised for their fur. FR07230 POULTRY AND BIRDS FR01235 BUSINESS ACTIVITIES AND BUSINESS PURSUITS Check box on left if particular business activity or pursuit applies Check box on right only if fees chared for that activity/pursuit Even if activity doesn t generate income it still must be declared Archery Ranges Athletics or Sports Activities Auctioneering for Third Parties Bartering of Goods or Services Beaches Breeding Cats, Dogs, or Rabbits Campgrounds Cabin or Vacation Rental Christmas Tree Farm Construction / Remodeling / Updating Indicate Project Cost Here: Keep Project Cost separate from all other receipts Insured is using third party, insured contractors Corn Mazes Custom Farming/Ranching (subcontract to third parties) Daycare, Foster Care, Misc. Education Farm Machinery Operations for Third Parties Farmers Markets/Concession Stands/Restaurants/Shops - off the insured s premises Feed, Grain, Hay Dealers, but only if sales off-premises Feedlots/Containment Operations/ Yard Confinement, but only If for third parties Fishing including Tournaments Fishing Piers (Oceanside piers prohibited) Fruit or Vegetable Harvesting for Third Parties Annual Receipts Total Acres Number of Head Annual Receipts Total COMBINED Receipts for all Business Activities and Business Pursuits Do NOT include: Receipts from leases related to Oil & Gas Facilities and/or Wind Turbines Construction Project Costs Page 12 of 15

13 FR01235 BUSINESS ACTIVITIES AND BUSINESS PURSUITS (continued) Check box on left if particular business activity or pursuit applies Check box on right only if fee is charged for that activity/pursuit Even if activity doesn t generate income it still must be declared Grain Storage for Third Parties Guides and Outfitters Hunting by Third Parties on Insured s Premises Land Leased to Third Parties Structures (including Dwellings) Leased to Third Parties Livestock Dealers/Commission Merchant for Third Parties Livestock Sales done for Third Parties Meat Processing done for Insured or Third Parties Nursery/Garden Retail Sales off the Insured s Premises Oil and Gas Well Facilities (must be owned/operated by third party) Do NOT include lease/royalty payments in receipts total Orchard or Vineyard Operations Performed for Third Parties Packing House Operations for Third Parties Picnic Grounds offered for use by Third Parties Pick-Your-Own Fruits, Nuts, Vegetables Playground offered for use by Third Parties Produce Handling or Packing for Third Parties Retail Stores Not Food On or Off the Insured s Premises Rodeos on the Insured s Premises Smoking of Meat/Fish/Seafood for Insured or Third Parties Snow Removal for Third Parties Special Events for Third Parties (corn maze, pumpkin patch) Stabling of Animals for Third Parties Stockyards that have animals owned by Third Parties Tours of Premises offered to Third Parties Towers owned/maintained by insured up to 72 feet in height Trails Third Party Use (only foot hiking trails acceptable) Wind Turbines (must be owned/operated by third party) Do NOT include lease/royalty payments in receipts total Wine Manufacturing, Processing, or Retail Sales ATV s, SNOWMOBILES, BOATS, BUNKHOUSES, OWNER-OCCUPIED DWELLINGS, LAKES, PONDS, POOLS, RESERVOIRS, SWIMMING POOLS ATV s: Prohibited: Recreational use, use by third parties and 3- wheelers Snowmobiles: Prohibited: Recreational use and use by third parties FR45523 Boats: Maximum 50 hp engine & maximum 26 foot length FR09253 Bunkhouses or Dormitories: Total number of buildings (up to 12 beds count as one building) FR09250 Dwellings: Owner Occupied only (rentals are rated under step 3) FR40017 Lakes, Ponds, Reservoirs: Combine all into one total acreage figure FR48925 Swimming Pools: Required: Fully fenced, self locking gates, depth marked, rules posted, safety equipment provided. Only below ground pools are to be counted Total Number Total Number Total Number Total Buildings Total Number Total Acres Total Number Page 13 of 15

14 ADDITIONAL INSUREDS (A.I.) - LOSS PAYEES WAIVERS OF SUBROGATION Circle only those that apply 1. A.I. Loss Payee Waiver of Subrogation Entity / Address: Relationship to Insured: 2. A.I. Loss Payee Waiver of Subrogation Entity / Address: Relationship to Insured: 1. A.I. Loss Payee Waver of Subrogation Entity / Address: Relationship to Insured: 2. A.I. Loss Payee Waver of Subrogation Entity / Address: Relationship to Insured: 3. A.I. Loss Payee Waver of Subrogation Entity / Address: Relationship to Insured: 4. A.I. Loss Payee Waver of Subrogation Entity / Address: Relationship to Insured: 5. A.I. Loss Payee Waver of Subrogation Entity / Address: Relationship to Insured: TOTAL ANNUAL RECEIPTS FROM ALL OPERATIONS Includes all farm, ranch, business activities or business pursuits intended to be covered under this policy VACANT Vacant since (date): SEASONAL OCCUPANCY Seasonally vacant (list only periods that exceed 30 days): to to to to Page 14 of 15

15 FARM/RANCH PREMISES DIAGRAM Identify all buildings, lakes, ponds and storage tanks Identify any structure(s) that are not to be insured for property (if applicable) Indicate distance between structures I understand misrepresentation or omission of material facts in this application will be cause for cancellation and may void coverage. Applicant Signature / Date: Agent s Signature / Date: Page 15 of 15

FARM AND RANCH APPLICATION

FARM AND RANCH APPLICATION Date: Agency: Status (circle one): Quote Renewal Expiring Policy Number: Effective Dates: to APPLICANT INFORMATION Named Insured: Insured s Mailing Address: Insured s Phone Number(s):