Individual Partnership Corporation Other New Renewal of Policy #: Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D

Size: px

Start display at page:

Download "Individual Partnership Corporation Other New Renewal of Policy #: Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D"

Eileen Morgan
5 years ago
Views:

1 Combination TM Package AND Application Fire Policy Number: RAM Mutual Insurance Company P.O. Box 308 Esko, MN 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 #: Social Security #: Insured: Annual Monthly* RAM-Pay* *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 Included $1,000 $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 Section Twp. Range Township Fire # County State Interest Owner or Tenant 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 -

2 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 No K. Wind generating equipment: 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? C. Are premises used for any business or professional purposes other than farming? Yes No If Yes, explain: I. Do all steps have adequate handrails? Yes No J. Condition of farm equipment: Good Fair Poor Has safety equipment been altered or removed? Yes No - 2 -

3 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 policy cancelled 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 - 3 -

4 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 CLASS A-2 DWELLINGS - Photos Required Limited Basic Broad $ Residence $ Household Personal Property $ Increase in Living Costs $ $ Dwelling x x $ 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-3 MOBILE HOMES - Photos Required CLASS E SCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad $ Home (Age/Make) x x $ x x $ Additions x x Limited Basic Broad $ Scheduled Farm Personal Property (From 7 on pg. 7) $ Portable Crop or Grain Dryer (515) $ Household Personal Property $ Farm Operations Record Expenses (533) $ Increase in Living Costs $ x x $ Sub-Total $ $ Sub-Total CLASS F UNSCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad Special Code $ Unscheduled Farm Personal Property (From 8 on pg. 7) - 4 -

5 CLASS G-1 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required Superior - Minimum of 90% of Replacement Cost Replacement Cost, Special Form, Opt. Cov. P, & Coverage Adjustment Incl. CLASS G-2 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required (Includes Opt.Cov. P) Minimum of 50% of Replacement Cost Above Average - ACV basis G-1S (Asphalt Shingles) Limited Basic CLASS G-3 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required Minimum of 25% of Replacement Cost Standard - ACV basis CLASS H SPECIAL HAZARDS - Photos Required Limited Basic Limited Basic - 5 -

6 Class MISCELLANEOUS PROPERTY ACORD Form Required on All Commercial Property Check company manual for rules and binding authority. Code Code Code $ x x OPTIONAL COVERAGES (TM Coverage Only) OPTIONAL COVERAGES 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) Yes No $ Yes No $ Livestock Confinement DO NOT BIND Yes No $ Yes No $ Special Form - Farm Machine Yes No $ Yes No $ Leased, Rented, or Borrowed Farm Machinery Coverage Yes No $ Yes No $ Equipment Breakdown Yes No $ Yes No $ Yes No $ Yes No $ - 6 -

7 FARM PERSONAL PROPERTY INVENTORY SCHEDULED FARM PERSONAL PROPERTY UNSCHEDULED FARM PERSONAL PROPERTY LIVESTOCK Number Value Total CATTLE Dairy $ $ $ Feeder $ Stock $ $ Registered $ SHEEP $ $ $ HOGS $ $ Feeder $ $ 1 TOTAL LIVESTOCK $ POULTRY $ $ 2 TOTAL POULTRY $ HAY, STRAW, & FODDER $ $ $ 3 TOTAL HAY, STRAW, & FODDER: $ GRAIN, FEED, & SUPPLIES $ $ $ $ $ Farm $ Veterinary $ Fuel Oil & $ $ Commercial $ Ground $ 4 TOTAL GRAIN, FEED, & SUPPLIES $ Item (Describe) TRACTORS No. 1 $ No. 2 $ No. 3 $ No. 4 $ Garden Tractor $ Skid Loader $ $ Combine No. 1 $ Combine No. 2 $ Combine Heads $ Swather $ Picker/Sheller $ Other Self-propelled $ $ $ Port. Elevator $ Port. Auger No. 1 $ $ Port Auger No. 2 $ $ Policy provisions require individual scheduling of above items when not being used in Unscheduled Farm Personal Property. The following items may be optionally scheduled. 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 $ FARM MACHINERY & EQUIPMENT Value 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. $ $ $ $ TOOLS & MISC EQUIPMENT Electric Motors $ Fuel Tanks $ Port. Generator $ Spare Parts $ Power Tools $ Hand Tools $ Welder $ Compressor $ Bldg/Fencing Material _ $ $ $ 5 TOTAL FARM MACHINERY & EQUIP. $ INSTALLED EQUIPMENT (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 $ 6 TOTAL INSTALLED EQUIPMENT $ 7 TOTAL SCHEDULED VALUE 8 (Add 1 through 6 - transfer amount to page 2) $ TOTAL UNSCHEDULED VALUE (Add 1 through 5 - transfer amount to page 2) $ Comments: -7-

8 SCHEDULE OF ANNUAL LIABILITY RATES COVERAGE APPLIES? Yes No CODE # DESCRIPTION PERSONAL LIABILITY 50, , , ,000 1,000,000 MEDICAL PAY Add l for each $1,000 (max $5,000) PREMIUM Farmers CPL (FCPL) 1 Dwelling, 1 Set of Buildings, up to 320 Acres Additional Acreage Charge 321 to 1,000 Acres Over 1,000 Acres Personal Liability (CPL) Up to 40 Non-Farm Acres Additional Acreage Charge Additional Named Insured - Premises Only Liability Additional Named Insured - Personal Liability Additional Residence Premises - Rented to Others One Family Two Family Additional Residence Premises Additional Set of Buildings Business Activities Custom Farming: Rates per $100 of receipts Apply only if receipts exceed $1,000 Damage to Property of Others (Coverage N) $1,000 included in policy-max Limit $10,000 Employers Liability If payroll is between $8,000 and the amount required by MN Comp Law for Work Comp Family Med. Pay Ages only ($100 Deductible) Non-Farming Discount - N/A with CPL Horse Exposure Charge 1-2 Horses 3-5 Horses 6-10 Horses Livestock Exposure Charge Office, Professional, Private School, or Studio Use Personal Injury (No Medical) Property in Control of Insured Recreational Vehicles (Off Premises) (Fully Earned) Watercraft Liability (Motors Over 100 HP) Jet-Driven Watercraft Other: TOTAL - 8 -

9 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 90 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 agent, North Star Mutual or Itasca Mutual to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit, 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 appeal to the Commissioner (Director) (MN) - Minnesota Commission of Commerce, 85-7th Place East, Suite 500, St. Paul, MN If this application for insurance is accepted, I grant permission to North Star Mutual or Itasca 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. I understand that this temporary authorization will expire as soon as one of the following occurs: (a) The above named companies make the underwriting decisions 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. 8. "Delux Dwelling" and "Delux Dwelling Plus" dwelling coverages and G-1 outbuilding coverages will automatically be updated on anniversary based on changing dwelling/building construction cost factors. 9. the check box Yes/No areas accurately indicate desired coverage. 10. 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: AGENT S SIGNATURE: DATE: - 9 -

10 WORKSHEET PREMIUM COMPUTATION FIRE WIND Class Insurance Amount Rate Premium Premium Premium Total P ersonal Property I ncrease in Living Costs FIRE WIND Class Insurance Amount Rate Premium Premium Premium Total OPTIONAL COVERAGES: List and Describe Total Insurance Coverage Total Fire Premium Total Wind Premium Wind Zone Adj. Liability Premium Total Fire Premium Inland Marine Credits/Surcharges IRPM % Surcharge Total Policy Yes No Yes No Q Added Perils for Refrigerated Food Products (TM Only) SPC Special Package of Coverages 6J Percentage Modified Replacement Cost for Dwellings SPC Special Package of Coverages - TM 7S Amended Theft 7P Leased, Rented, or Borrowed Farm Machinery, Vehicles 6R Cab Glass - Scheduled & Equipment of Others 6U Collapse - Weight of Ice, Snow, or Sleet 6T Loss of Income or Rent 7Q Collapse - Weight of Ice, Snow, or Sleet 7N Loss of Income 7W Collision and/or Overturn 7R Loss of Use or Income 7Y Collision and/or Overturn S Peak Season Inventory 6S Debris Removal K Replacement Cost Endorsement - Household 6W Deferred Loss Payment Personal Property 6X Deferred Loss Payment 7H Earthquake 7X Expanded Vehicle Damage T Farm Extra Expense R Glass Coverage - Unscheduled $ Ded. J Replacement Cost Provision V Restriction of Individual Policies 7J Theft Coverage Extension 7U Backup of Sewers, Drains, or Sump Systems

Individual Partnership Corporation Other New Renewal of Policy #: Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D

Farm TM41 3-09 Partner AND Application Fire Policy Number: RAM Mutual Insurance Company P.O. Box 308 Esko, MN 55733 Individual Partnership Corporation Other New Renewal of Policy #: Name: From: To: Address: