State: Kentucky Filing Company: State Farm Mutual Automobile Insurance 19.0 Personal Auto/ Private Passenger Auto (PPA)

SERFF Tracking #: SFMA-128991186 State Tracking #: Company Tracking #: PV-29973 State: Kentucky Filing Company: State Farm Mutual Automobile Insurance TOI/Sub-TOI: 19.0 Personal Auto/19.0001 Private Passenger Auto (PPA) Product Name: PV-29973 Project Name/Number: PV-29973/PV-29973 General Information Project Name: PV-29973 Status of Filing in Domicile: Not Filed Project Number: PV-29973 Domicile Status Comments: Reference Organization: Reference Number: Reference Title: Advisory Org. Circular: Filing Status Changed: 05/02/2013 State Status Changed: 05/02/2013 Deemer Date: 06/25/2013 Created By: Robin Dunagan Submitted By: Robin Dunagan Corresponding Filing Tracking Number: Filing Description: We respectfully request your approval of the enclosed forms: 135-4027 KY.6 Multi-Vehicle Insurance Application, which replaces 135-4027 KY.5. This application is used for both Personal and Commercial lines. The changes include: Applicant Section Replaced Township field with County Replaced Nature of Business and Ownership field with Business Description Added Total number of vehicles owned and operated field Replaced Number of Years field with Year Business Established Replaced Legal Entity field with Type of Business Ownership Added Materials hauled subject to Federal Hazardous Materials Regulations and Permits? field ENOL Section Updated the Yes See non-owned rules section of Auto Rate Manual to Yes See non-owned rules section of the Auto Rate Manual. Complete and attach the Employer s Non-Owned Car Liability Report. Also increased the font size and bolded. Increased the font size and bolded the ENOL/HC Physical Damage needed? Contact Underwriting field Vehicle Description and Rating Information Section Added Cab/Chassis field Updated the Body Type and Size field to Body Type Replaced Mounted Special Equipment and Cost Price New field with Describe Permanently Mounted Special Equipment Added Special Equipment field Replaced Length of Added Body and Capacity field with Added Body Removed the Multi Rear Axle field Updated the Gross Vehicle Weight (GVW) field to Gross (Combined) Vehicle Weight (GVW/GCVW) Replaced Indicate Number of trips per year beyond a 50 mile radius field with Radius (farthest distance vehicle is driven from garaging location at least 4 times annually) Replaced Annual Mileage field with Distance Driven Annually Removed the Principal Cities Traveled to and through field Replaced Territory Number field with Territory Based on Garaging Location Coverages Section Under Office Use Only replaced field with Total added body & spec equip Under Office Use Only deleted Class field Trailer Description Information Section Added GVW/GCVW trailer field Deleted the Length field PDF Pipeline for SERFF Tracking Number SFMA-128991186 Generated 05/06/2013 01:39 PM

New Reinstatement Transfer Multi-Vehicle Insurance Application (To be used for Fleets, Buses, and Related Vehicles) Office Use Qualifying Policy Number Replaces Policy Number Other State Farm Insurance Life Health Financial Services CLUP/PLUP Fire - Policy Number or Name Business Name or Applicant's Name Please Print Last First Middle or Initial In City Yes No Telephone Number H B Mailing Address Number and Street/Rural Route Number City State ZIP Code County APPLICANT Address of Principal Garaging if different Business Description Number and Street/Rural Route Number City State Total number of vehicles owned and operated KY Year Business Established (Ex: 1985) ZIP Code County Type of Business Ownership Attach 5 year Loss Run Report and 5 year premium from prior carrier(s) Exact expiration date of current policy MM/DD/YYYY Date quotation requested MM/DD/YYYY Tax ID Number Are any federal or state filings required? Yes No If yes, give names of commissions involved Materials hauled subject to Federal Hazardous Materials Regulations and Permits? Yes No MC/USDOT Number ENOL Employers Non-Ownership Liability required? No Yes - See Non-Owned Rules section of the Auto Rate Manual. Complete and attach Non-Owned Car Liability Report. Hired Auto coverage desired? No Yes - provide estimated annual cost of hired autos $ ENOL/HC Physical Damage needed? Contact Underwriting ENOL Limits of Liability SCHOOL BUS School Buses: The following must be completed Number of days in school term Number of days in summer term Number, description and destination of approved use trips Owned by School District or Municipality Yes No If a School Bus Contractor, explain use of Buses and name of School District in Remarks 1001677.2 Page 1 of 7 114681 04-10-2013 135-4027 KY.6

Vehicle Number Lien Code Lienholder Mailing Address ZIP Code LIENHOLDER DRIVERS Complete for all drivers. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Name Marital Status Sex Owners/ Officers vs. Employees During the past 5 years any: Suspensions Accidents Violations or Revocations Yes No Yes No Yes No Birthdate MM/DD/YYYY Driver's License Number/State 1001677.2 Page 2 of 7 114681 04-10-2013 135-4027 KY.6

Vehicle Description and Rating Information If Physical Damage Coverages are desired for a Trailer, list the trailer as a separate unit in this section Vehicle Number Year Make and Model 1 Cab/Chassis Body Type Vehicle Identification Number Describe Permanently Mounted Special Equipment Special Equipment Added Body Prior Damage Gross Vehicle Weight (GVW) No If yes, Show Damage Indicator (See page 7) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 1001677.2 Page 3 of 7 114681 04-10-2013 135-4027 KY.6

Commercial Vehicle Description & Rating Information (cont d) Private Passenger Applies to all Vehicles Vehicle Number Use of Vehicle 2 Radius (farthest distance vehicle is driven from garaging location at least 4 times annually) 3 Use of Vehicle 2 Principal Operator (Driver Number) Distance Driven Annually Territory Based on Garaging Location 4 Odometer 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 1001677.2 Page 4 of 7 114681 04-10-2013 135-4027 KY.6

1Vehicle Number BIPD No-Fault Coverage Medical Payments Limit Limits Aggregate Deductible Coverages (Indicate Limits for Coverages Desired) Guest No-Fault Comprehensive Coverage (Excluding motorcycles) Deductible Amount Collision Deductible Amount Uninsured Motor Vehicle Limits Underinsured Motor Vehicle Limits Kentucky Municipal Surcharge Tax Other 5 (Show coverage designation) DRG Office Use Only Total added body & spec GRG equip 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Total Premium For Use Once Coverage is Bound $ Remittance Received $ Balance Due $ The Total Premium Shown Above is for 12 Months Office Use Only PMF: SFPP Account Number 1001677.2 Page 5 of 7 114681 04-10-2013 135-4027 KY.6

Trailer Description Information - if Physical Damage Coverages are desired, list as a separate unit in the Vehicle Description and Rating Information section Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number 1 2 3 4 Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number TRAILERS 5 6 Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number 7 8 9 Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number Year Make Model GVW Trailer Body Type Trailer Use Vehicle Identification Number 10 1001677.2 Page 6 of 7 114681 04-10-2013 135-4027 KY.6

Date Time Approved By Date Date and Time of Application (MM/DD/YYYY) A.M. P.M. Agent's Code For Underwriting Use Only Effective Date BINDER (MM/DD/YYYY) State Farm Mutual Automobile Insurance Company of Bloomington, Illinois, hereby binds as of the requested effective date for a period of 30 days from such date, the insurance applied for, subject to all of the terms and conditions of the vehicle policy and applicable endorsements in current use by such Company. The issuance by the Company of the Declarations Page of the policy applied for voids this binder. APPLICATION By submission of this application, you agree that: (1) You have read this application, (2) your statements on this application are correct, (3) statements made on any other applications on this date for automobile insurance with this company are correct and are made part of this application, (4) you are the sole owner of the described vehicle(s) except as otherwise stated, and (5) the limits and coverages were selected by you. IT IS FURTHER UNDERSTOOD AND AGREED THAT NO INSURANCE IS EFFECTIVE UNDER THIS AGREEMENT (A) UNLESS THE BINDER IS COMPLETED DESIGNATING THE COMPANY ACCEPTING THIS APPLICATION OR (B) UNTIL THE DATE THE POLICY OR BINDER IS ISSUED BY THE COMPANY ACCEPTING THIS APPLICATION. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Consumer reports, including credit and insurance loss history reports, may be ordered in conjunction with this application. We may also obtain and use a credit-based insurance score developed from information contained in these reports. We may use a third party in connection with the development of your insurance score. These reports provide information that assists with determining your eligibility for insurance and the price you are charged. B-Body G-Glass H-Hail M-Misc. B G 01 02 03 04 05 06 07 08 09 10 11 12 13 14 00 03 06 09 12 See Prior Damage Diagram Explain in Remarks H M Remarks: Business Website Address; items hauled and vehicle numbers; insurance certificate needs; endorsements needed; prior damage; Additional Insured needs; etc. NOTES 1. School Bus - Indicate seating capacity. 2. Items Hauled/Vehicle Use - Describe items hauled in Remarks. If vehicle use is not otherwise listed on application, explain in Remarks. 3. School Bus/Church Bus - Indicate the number of school days the school bus will be used. Church Bus - Show radius of operation. 4. Commercial - If used predominantly in a territory other than that of principal garaging, explain in Remarks. 5. School Bus - If appropriate, indicate Fire, Wind, and Theft Coverages. 1001677.2 Page 7 of 7 114681 04-10-2013 135-4027 KY.6