COMBINATION PACKAGE APPLICATION

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1 COMBINATION PACKAGE APPLICATION New Renewal of: From: To: Fire Policy Number: AND (12:01 a.m. at address of named insured) Box 48 Cottonwood, Minnesota Individual Partnership Corp. Other Agency and Mail Address Agent No: Applicant and Mail Address: Phone #: Address: Address: Name: Drivers License #: Name: Drivers License #: BILLING MODE: Annual Semi-Annual Quarterly Other General Agents Use Only GA's Initials BILL PREMIUM TO: Insured Agency Mortgagee Application has been reviewed and approved. PERILS INCLUDED: Fire Windstorm and Hail FPL PL Inland Marine Other DEDUCTIBLE: $250 $500 $1,000 (Base) $1,500 $2,000 $2,500 $5,000 $10,000 MORTGAGEE C/D NAME AND ADDRESS: MORTGAGEE C/D NAME AND ADDRESS: DESCRIPTION OF PREMISES: List all property with buildings owned, leased, rented or maintained. List primary location first. Loc. No. of Sets of Qtr. Sec-Twp-Range Int No. Dwlgs. Bldgs. Acres Sec. Numbers Township County State (O/T) 911 Address Bare Land Total Additional Acres - with no buildings - owned, leased, rented or maintained not listed above. TOTAL ACRES UNDERWRITING GUIDE - FURNISH PHOTOS OF ALL BUILDINGS All questions must be answered or app. may be returned. If asked to explain or list, please list question # & information on a separate memo & attach. 1. Date of last on-site inspection: By whom? 2. Principal farm operations are: Grain Dairy Livestock Poultry Occupation: 3. General housekeeping and condition of premises: Excellent Good Fair Poor 4. DWELLING: A. Age: Yrs. B. Smoke Alarm(s): Yes No C. Fire Extinguisher(s): Yes No D. Wiring: Yrs.; #Amps: Rewired: Completely Partially E. Plumbing: Yrs. F. Occupancy: Owner Tenant Unoccupied Vacant Seasonal Under Construction G. Central Heating: Yes No; Age of Heating Unit(s): Yrs.; Type: H. Any type of solid fuel heating equipment: Yes No; Type: Central Space Fireplace; Age: Yrs.; Type of Chimney I. Siding Type and Condition: J. Roof: Age: Yrs. Type: Asphalt Shingles Wood Shakes Metal Other: K. Solar Heating: Yes No; If yes, explain on a separate memo. L. Wind Generating Equipment: Yes No 5. OUTBUILDINGS: If an answer to a question is yes, list the building(s) and explain on a separate memo and attach. A. Occupied by: Owner Tenant Off Premises Tenant B. Condition of buildings: Excellent Good Fair Poor C. Any building not used for designed purposes? 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 CF-1000 (Ed. 4-18) - 1 -

2 6. PL/FPL SURVEY: A. Does applicant have: Seasonal Property? Yes No; Business Office or Incidental Sales? Yes No; Rental Property? Yes No; Trampoline? Yes No; Roadside Stand? Yes No; If yes, explain seperate memo. B. Swimming Pool? Yes No; Above Ground or Below Ground; Diving Board/Slide? Yes No; Fence around pool? Yes No; (Provide Picture of Pool). C. Does applicant do custom farming? Yes No; Type: Custom Spraying involved? Yes No; Gross Annual Custom Farming Receipts? D. Are premises used for any business or professional purposes other than farming? Yes No: If yes, explain on a separate memo. E. Does applicant own any livestock? Yes No F. Are there horses on premises? Yes No; Owned? Yes No; # ; Type: Boarded? Yes No; # ; Type: G. Does applicant own dog(s)? Yes No; If yes, what breed(s)? Has the dog(s) ever bitten anyone? Yes No H. In what condition are applicant's fences? Good Fair Poor I. Do all steps have adequate handrails? Yes No J. Condition of farm equipment: Good Average Poor; Has safety equipment been altered or removed? Yes No 7. PREVIOUS CARRIER: Was policy cancelled or non-renewed? Yes No; If yes, why? 8. OTHER INSURANCE: A. Is there other insurance? Yes No; If yes, with whom? B. Is there other insurance with NORTH STAR? Yes No; If yes, policy number(s): 9. How long has Agent personally known applicant? Does Agent personally recommend issuance of this policy? Yes No LOSS EXPERIENCE: NONE APPLICANT'S SIGNATURE List all losses in last 5 years and any losses ever over $10,000. (Dates, Type and Amount) COMMENTS: WIND COMPANY ONLY Underwriter: Date Entry: Checked By: MAFMIC FORMS AVAILABLE Yes/No Yes/No x TP1 General Policy Provisions J Replacement Cost Coverage (Buildings) Q Added Perils for Refrigerated Food Products K Replacement Cost Endorsement (Coverage C) 7S Amended Theft (Expanded Coverage) 6R Scheduled Cab Glass (Coverage E or F) AM Amended Failure to Match Optional Deductible $ (Included A1 & A5 - Not Available A2 & A3) 7C Amended Vandalism or Malicious Mischief and Theft 7U Backup of Sewers, Drains or Sump Systems (Expanded Coverage) (Coverage A - Coverage C) $ 7D Amended Vandalism or Malicious Mischief 6K Blizzard Death Coverage - Livestock (Expanded Coverage) P Collapse - Due to Weight of Ice, Snow or Sleet 7A Collapse - Weight of Ice, Snow or Sleet (Coverage E or F) 7W Expanded Collision and/or Overturn-Plus (Coverage E or F) 7Q Collapse - Weight of Ice, Snow or Sleet (Coverage G) 7Y Expanded Collision and/or Overturn (Coverage E or F) 6W Deferred Loss Payment Z Coverage Adjustment Endorsement 6X Deferred Loss Payment 6S Debris Removal $ W Deferred Loss Payment 7X Expanded Vehicle Damage X Deferred Loss Payment T Farm Extra Expense 7H Earthquake R Cab Glass (All Mobile Farm Equipment) Optional Deductible $ 7P Leased, Rented or Borrowed Farm Machinery, Vehicles and Equipment of Others (Coverage E) 6P Livestock Confinement Coverage 7N Loss of Income (Coverage G) 6J Modified Replacement Cost (Coverage A) 7R Loss of Use or Income (Coverage G) (Agreed Percentage) 6T Loss of Income or Rent 7B Non-Depreciation of Repairs (Coverage E or F) V Restriction of Individual Policies S Peak Season Inventory Farm Personal Property 7J Theft Coverage Extension U Recreational Equipment (Construction Material & Supplies) (Coverage A or G) - 2 -

3 CODE AMOUNT DESCRIPTION Fire/Wind CLASS A-1 and A-5 RESIDENCE A-1 Delux Dwelling: Basic Broad Special A-5 "Delux Dwelling Plus": x Special $ Residence $ Household Personal Property $ Additional Living Expense $ Sub-Total Type of Roof Roof Year Metal Roof Discount (Cosmetic Damage Exclusion applies) Replacement Cost - Household Goods (Option - Delux Dwelling Only) Special Form - Household Goods (Option - Delux Dwelling Only) New/Upgraded Home Component Discount Protected Partially Protected Unprotected CLASS A-2 DWELLINGS Limited Basic Broad Special $ Dwelling x $ Household Personal Property $ Additional Living Expense $ Sub-Total Type of Roof Roof Year Metal Roof Discount (Cosmetic Damage Exclusion applies) Replacement Cost - Household Goods (Minimum 50% of Dwelling Value) Special Form - Household Goods Protected Partially Protected Unprotected CLASS A-3 MOBILE HOMES Limited Basic Broad $ Home (Age/Make/Dimensions) x $ Additions x $ Household Personal Property $ Additional Living Expense $ Sub-Total Replacement Cost - Household Goods (Minimum 50% of Dwelling Value) Protected Partially Protected Unprotected CLASS E SCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad Special - Farm Machinery $ $ Scheduled Farm Personal Property (From 7 on Page 6) $ Portable Crop or Grain Dryers $ $ $ Sub-Total CLASS F UNSCHEDULED FARM PERSONAL PROPERTY Limited Basic Broad Special - Farm Machinery $ $ Unscheduled Farm Personal Property (From 8 on Page 6) CLASS G-1 FARM BARNS, BLDGS, STRUCTURE (Superior) Replacement Cost Provisions, Weight of Ice,Sleet & Snow and Special Form Included CF-2018 (Cosmetic Exclusion Applies) (Minimum - 90% of Full Replacement Cost Required) Comments/Restrictions G-1S - Shingled or Open Sided $ Sub-Total - 3 -

4 CODE AMOUNT DESCRIPTION Fire/Wind CLASS G-2 FARM BARNS, BLDGS, STRUCTURE (Above Average) Weight of Ice, Sleet & Snow Included (Minimum - 50% of Full Replacement Cost) CF-2018 (Cosmetic Exclusion Applies) Limited Basic Comments/Restrictions G-2S - Shingled or Open Sided $ Sub-Total CLASS G-3 FARM BARNS, BLDGS, STRUCTURE (Standard) (Minimum - 25% of Full Replacement Cost) CF-2018 (Cosmetic Exclusion Applies) Limited Basic $ Sub-Total Comments/Restrictions CLASS H SPECIAL HAZARD & LOW VALUE OUTBUILDINGS (Permanent buildings covered for total loss only) Limited Basic $ x $ x $ x $ x $ Sub-Total Yes/No OPTIONAL COVERAGES $ Total Fire Department Serviced (Fire Company Only) $ Submersible Pumps $ Underground Wiring $ Underground Service Line Coverage $ Farm Operations Records Coverage $ Peak Season - Item: From: To: $ Loss of Income (Dairy and Hogs) $ Farm Extra Expense $ Leased, Rented or Borrowed Farm Machinery Coverage $ Identity Fraud Expense Installed Equipment Breakdown Blizzard Death (Livestock) Livestock Confinement Coverage (Separate Application Required) Special Package of Coverages - 2nd Unit Super Star Credit Companion Policy Discount Auto Policy # $ $ $ $ GRAND TOTAL COVERAGE - 4 -

5 WORKSHEET DWELLING REPLACEMENT COST ESTIMATE - Use the MS/B RCT software program and ATTACH THE RCT PRINTOUT. CLASS G - FARM OUTBUILDINGS SCHEDULE Interior Dimensions/ Total Cost Replace- Actual Amount Loc. Type of Framework Bushel Capacity BUILDING Type of Year Square Per Sub- Fixed ment Cash of Ins. No. Class USE Wood/Steel/ Exterior Roofing Built L W H Feet Sq. Ft. total Equip. Cost Value Requested Pole/Block AGE Type of Foundation Concrete Floor Insulated & Covering Pit Under Building Wired Heated Additional Information:

6 SCHEDULED FARM PERSONAL PROPERTY LIVESTOCK CATTLE # Value Total Dairy Cows Heifers Dairy Calves Feeder Cattle Stock Cattle Bulls Registered Cattle SHEEP Ewes Rams Lambs HOGS Sows Boars Feeder Pigs HORSES 1 TOTAL LIVESTOCK... $ Hens Fryers POULTRY 2 TOTAL POULTRY... $ Hay Straw Fodder/Silage HAY, STRAW AND FODDER 3 TOTAL HAY, STRAW & FODDER. $ GRAIN, FEED AND SUPPLIES Corn Soybeans Wheat Oats Sunflowers Farm Chemicals Veterinary Supplies Fuel, Oil & Grease Paints Commercial Feed Ground Feed 4 TOTAL GRAIN, FEED & SUP... $ farm personal property inventory UNSCHEDULED FARM PERSONAL PROPERTY FARM MACHINERY AND EQUIPMENT Value Tractors: No. 1 $ No. 2 $ No. 3 $ No. 4 $ No. 5 $ No. 6 $ Garden Tractor $ Skid Loader $ Combine No. 1 $ Combine No. 2 $ Combine Heads $ Combine Heads $ Swather $ _ 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. Following items may be optionally scheduled. Bale Racks & Trailers $ Beet Defoliators $ Beet Lifters $ Beet Planters $ 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/Bine $ Hay Stacker Loader $ Hay Stack Mover $ Livestock Trailer (Unlicensed)_ $ Mach. Trailer (Unlicensed) $ Manure Spreader $ Mower $ Plows $ Potato Digger $ Rakes $ Rotary Tiller/Hoe $ Row Cultivator $ Silage Wagon $ Silage Cutter/Blower $ Stalk Cutter $ Snow Blower $ Spraying Tank $ Tractor Loader $ Vaculator $ TOOLS AND MISC. EQUIPMENT: Electric Motors $ Fuel Tanks $ Port. Generator $ Spare Parts $ Power Tools $ Hand Tools $ Welder $ Compressor $ Bldg/Fencing Material $ 5 TOTAL FARM MACHINERY AND EQUIPMENT... $ INSTALLED EQUIPMENT (Must be Scheduled if not included in building value) Bulk Tank/Cooler $ Milk House Equip. $ Milking Mach. Equip. $ Hog House Equip. $ Poultry Equipment $ Silo Unloader $ 6 TOTAL INSTALLED EQUIPMENT... $ 7 TOTAL SCHEDULED VALUE 8 TOTAL UNSCHEDULED VALUE (Add 1 through 6 - transfer amount to page 3) $ (Add 1 through 5 - transfer amount to page 3) $ Comments: INLAND MARINE COVERAGE - Attach Completed Inland Marine Application - 6 -

7 This is not Commercial Liability, consult your Agents Manual or Company for Commercial Coverages. LIABILITY - PERSONAL LIABILITY (PL) OR FARM PERSONAL LIABILITY (FPL) COVERAGE LIMITS: Coverage L - Personal Liability: Coverage M - Medical Payments to Others: Cov. Applies Limits of Liability Med Pay Each Yes/No (Med Pay 1,000 Incl) $50,000 $100,000 $300,000 $500,000 $1,000,000 Add'l $500 Premium BASE PL CHARGE (1 family) $ BASE FPL CHARGES - Including Employer's Liability for part time employees working 40 days or less per year 320 acres or less, 1 dwelling, 1 set of buildings $ acres, 1 dwelling, 1 set of buildings $ Over 1000 acres, 1 dwelling, 1 set of buildings $ Non-Farming Discount (Farm land not operated by insured/no making of hay and with 5 or less head of horses/other livestock) - Reduce the Base acres charge by 50% $ ADDITIONAL CHARGES Add'l Farm Premises with Bldgs. No. (Owned or Rented) $ Additional Residence Premises Maintained No $ (Secondary Locations, Seasonal Dwellings) Location: Incidental Office - Describe $ Livestock Owned - Liability Exposure Charge $ Babysitting (1-5 children) (1 charge) No. of Children N/A N/A $ Custom Farming, Per $ of Gross Receipts $ (When Custom Farming exceeds $5,000, charge applies to receipts in excess of $5,000) Estimated Receipts $ Customing Spraying, Spray Drift From Agricultural N/A N/A N/A N/A $ Horses (1-2 Included) (If over 10 horses, refer to Home Office) (Horses taken to parades or shows? Yes No) $ $ Inboard or Inboard/Outboard Motor Boats 30 M.P.H. & Under and Less than 26 feet $ Over 30 M.P.H. and Less than 26 feet $ Length Description Rated Speed (M.P.H.) H.P. Outboard Motor Boats (Standard Policy includes 50 H.P. and Under. Delux Dwelling Plus includes 100 H.P. and Under.) H.P. Make $ Note: For rating purposes, combine the H.P. of all outboard motors used together with any single watercraft owned by the insured. Partnership Endorsement, each Partner $ (1 Base FPL Charge plus this for each additional partner) Name: Relationship: Resides at Farm No.: Name: Relationship: Resides at Farm No.: Personal Injury (Does not include Medical Payments) $ Recreational Vehicles (Does not cover any 2 wheel vehicles) List Snowmobile(s) CC's List ATV(s) CC's Snowmobiles and ATVs (1 premium charge) $ Residence Premises Rented to Others No: 1 Family - Location: $ 2 Family - Location: $ Trampoline - $25 Charge... $ EMPLOYER'S LIABILITY (This does not replace Worker's Compensation coverage that may be required.) EACH FULL TIME EMPLOYEE, No $ (working 180 days per year or more) EACH PART TIME EMPLOYEE, No $ (working over 40 days but less than 180 days per year) DAMAGE TO PROPERTY OF OTHERS - $1,000 limit included (cannot be increased if custom farming is done) $10 per $1,000 of increase (maximum $10,000) (FPL only) Limit $ $ FARMER'S MEDICAL PAYMENTS - DESIGNATED INSUREDS AGES ($100 Deductible) Limit each person: $1,000 - $46 $2,000 - $58 $3,000 - $69 NAME DOB RELATIONSHIP $ Limit $ OTHER $ FOR COVERAGES OR RATING SITUATIONS NOT SHOWN, REFER TO HOME OFFICE TOTAL PREMIUM $ - 7 -

8 PREMIUM COMPUTATION FIRE WIND Class Insurance Amount Rate Premium WIND PREMIUM Class A-1 Personal Property Add'l Living Expense RATE PREMIUM OPTIONAL COVERAGES: List and Describe Total Ins. Amount Total Wind Premium Subtotal: Fire Premium Liability Premium Total Fire Premium Total Fire Premium Inland Marine Total Policy Premium AGREEMENT AND SIGNATURE OF APPLICANT AND AGENT - The signatures below certify that: (1) All property under Class E is listed to at least 80% of actual cash value. (2) Class F Property is insured to 100% of the Inventory Schedule. The applicant understands that an 80% coinsurance requirement applies and agrees to, at all times, maintain contributing insurance on the property insured to the extent of at least 80% 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% of replacement value. (4) All Class G-2 structures are insured to at least 50% 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) The check box Yes/No areas accurately indicate desired coverage. (8) (Inflation Protection) 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) As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting departments of the Township Mutual listed on the front and North Star 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 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 permission for subsequent amendments and renewals as long as the policy remains in force. If this application for insurance is accepted, I grant permission to the Township Mutual and North Star 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.) 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. 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 - 8 -

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

Combination TM41 3-09 Package 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: