FARM/RANCH APPLICATION

FARM/RANCH APPLICATION Policy # (If Renewal or Rewrite) Quote Bound Applicant s Name Address (RR# or Street) Town County State Zip Telephone FAX Email Individual Corporation Partnership Joint Venture Estate / Owner Occupied Tenant Absentee Owner Effective Date: Annual Semi-Annual (over $1,000) Quarterly (over $1,200) Physical Address Farm is located miles of (NOTE: List primary building location 1 st, other building locations 2 nd, other land 3 rd. More than 4 attach Separate Sheet.) Loc No. of Acres Bldgs. Yes/No Section Township Range County State Zip Code Protection Class Deductibles (Split Deductibles are available by Coverage on Farmers & Ranchers except Coverage on A & B.) Cov. A & B Coverage D Coverage E Coverage F $500 Ded. $1000 Ded. $2500 Ded. $5000 Ded. Basic Broad Special RC Roof (Cov. A only) Section I Coverages New House Credit Requested Limit of Liability Annual Premium A. Dwelling (Primary) Year Built or Remodeled Additional Dwellings (Total) (Schedule on Page 2) B. Unscheduled Personal Property (Household) RC Replacement Cost on: Carpet, Furnace & Air Conditioners C. Loss of Use (10% of A is included in F&R Policy) D. Scheduled Farm Personal Property E. Unscheduled Farm Personal Property (Blanket) 100% Inventory F. Barns, Buildings & Structures (Total) Earthquake Optional Section I Coverage Section II Coverages Limit of Liability Annual Premium G. Farm/Personal Liability Each Occurrence H. Medical Payments to Others Each Person/Each Accident /$25,000 Optional Section II Coverages Contract of Sale Clause or Mortgage Clause: (specify location or item) Loss Payable Clause: (specify item) Allen Financial Insurance Group / The Equestrian Group (ARIC 85068-00 ABIC 0DQ6) 1 of 6

COVERAGE A DWELLINGS & ADDITIONAL DWELLINGS Attach Costimator COVERAGE B DWELLINGS CONTENTS ACV RC COVERAGE F BARNS, OUTBUILDINGS & STRUCTURES For O/B Broad Perils Complete Questionnaire For O/B Collapse Complete Questionnaire Item # Loc. # Amt. RC/ACV Amount Coverage Description of Property Check if Woodburner (Must be RC for above coverage) Construction Net Broad Type Type Rate Perils Collapse Only Premium LOSS OF INCOME Description of Building $ Max. Cov. $10,000 Description of Building $ Sewer Backup Coverage (Texas Only) Yes No DIAGRAM, DIMENSION, DISTANCE OF BUILDINGS Sketch all buildings to scale, showing size and number of feet separating each structure. Each structure should be identified by name and/or item number. Buildings not insured should also be shown and identified. A clear up-to-date photo of each building, showing two sides of the structure and one slope of the roof, must be submitted. Indicate on picture location #, description and insurance amount. (Attach additional sheets for diagrams if needed.) N W E S Allen Financial Insurance Group / The Equestrian Group (ARIC 85068-00 ABIC 0DQ6) 2 of 6

FARM PERSONAL PROPERTY (Coverage D & E) Coverage D Scheduled Scheduling of all Farm Personal Property, except what is excluded in the policy conditions, is allowed. Coverage E Blanket ($25,000 minimum) Excluding Bulk Milk Tanks, Bulk Feed Tanks, Barn Cleaners, Pasteurizers, Boilers, Portable Buildings, or other Property excluded by the policy conditions. Check Coverages Desired: Cov. D Cov. E Cov. D & E Coverage Requirements: Scheduled 100% of ACV; Blanket 100% of ACV ATV S PROHIBITED ON COV. D OR E TOTAL INVENTORY REQUIRED FARM PERSONAL PROPERTY INVENTORY MOBILE MACHINERY & EQUIPMENT Year, Make, Model #, ACV MOBILE MACHINERY (CONT.) Description ACV $1,000 MAXIMUM PER ITEM MISCELLANEOUS EQUIPMENT Description ACV Tractor Baler Post Hole Digger Tractor Forage Harvester Log Splitter Tractor Silo Filler Chain Saws Tractor Ensilage Blower Power Generators Combine Silo Unloader Milking Machines Schedule Only Combine Packers Milk Cans, Racks Schedule Only Attachments Manure Loader Milk Cooler Schedule Only Manure Spreader (not bulk) Schedule Only Corn Head Dirt Blade Milking Supplies Schedule Only Grain Head Snow Plow/Blade Feeders (All) Other Fertilizer Appt. Waterers (All) Planter Sprayers Heaters (All) Stalk Chopper/Cutter Auger Elevator Farrowing Crates Mulcher Bale Elevator Electric Motors (No Irrigation) Drills, Seeders Other Port. Elvtr. Pumps (No Irrigation) Corn Sheller Wagon Hoist Fuel, Oil, Grease Corn Picker Auger Wagons Fuel Tanks Cultivators Ensilage Wagons Electric Fencers Field Cultivator Gravity Wagons Electric Fencers Rotary Hoe Other Wagons Compressors Discs Implement Trailer Fertilizer Harrows Hay Racks Fertilizer Tanks Plows Feed Grinder/Mill Herbicides, Sprays Chisel Plow Feed Mixer Welders Hay Rake Feed Carts Power Tools Hay Conditioner Grain Cleaner Hand Tools Hay Fluffer Port. Grain Drier (Not Batch) Tack, Stable Equip. Windrower Garden Tractor Building Materials Swather Roto Tiller Veterinary Supplies Mowers Back Hoe Other TOTAL MACHINERY $ TOTAL MISC. EQUIP. $ Allen Financial Insurance Group / The Equestrian Group (ARIC 85068-00 ABIC 0DQ6) 3 of 6

FARM PERSONAL PROPERTY INVENTORY (cont.) Animals valued over $2,000 per head must be scheduled. LIVESTOCK (Maximum coverage per animal $2,000) ACV # Head per head Beef Cows Beef Calves Beef Heifers Feeder Cattle Dairy Cows Bulls Sows Shoats Feeder Pigs Boars GRAIN, FEED, HAY & SEED # UNITS ACV Corn Soybeans Others Hay * Straw Silage Ground Feed Food Supplies Seed TOTAL GRAIN $ *Complete Questionnaire LIVESTOCK (cont.) ACV # Head per head Ewes Lambs Rams Horses Ponies TOTAL LIVESTOCK $ Allen Financial Insurance Group / The Equestrian Group (ARIC 85068-00 ABIC 0DQ6) 4 of 6

TOTAL BLANKET $ If Blanket, the following property is to be excluded: Peak Season Endorsement: Amount of Increase $ From To Rate Premium $ Explain Reason for Increase Milk Contamination Maximum $2,500 per occurrence Yes No Irrigation Equipment (Schedule Only -- $1,000 Deductible) If Additional Equip. Attach Schedule. Loc. Sec. Twp. Rge. ALL RISK SCHEDULED INLAND MARINE PERSONAL PROPERTY (Jewelry, Computers, etc.) All articles to be insured on a scheduled basis must be individually itemized with the amount of insurance applying to each article. Attach APPRAISAL or Bill of Sale Appraisal or state how values were substantiated. Or attach separate list of items. AMOUNT OF DESCRIPTION OF ARTICLE INSURANCE COVERAGE FOR LIVE ANIMALS IN TRANSIT Complete Supplemental Application Max. Cov. $2,000 per animal, $20,000 per load - $1.50 per hundred. MOTOR TRUCK CARGO COVERAGE Complete Supplemental Application Max. Cov. $25,000 - $2.50 per hundred. COVERAGE G SECTION II LIABILITY BASIC LIABILITY CHARGE: Total Acres Single Limits $500,000 $1,000,000 Med. Pmts. $ $ Additional set farm buildings with dwelling, location $ Additional set farm buildings without dwellings, location $ Additional residence maintained by insured, #, location(s) $ Additional residences rented to others, #, location(s) $ Custom Farming. Total Annual Receipts What type? $ Custom application of herbicides or chemicals. Yes No Employers Liability & Medical Payments. (Not available if applicant eligible for Workers Comp.) (Not avail. in CA or CO) No. of part-time employees Total days per yr: Under 40 Over 40 No. of full-time employees STOP GAP (Nevada) (Washington) $ COMPLETE EMPLOYERS LIABILITY QUESTIONAIRE Additional Insured Endorsement: Non-Comprehensive Name of Individual: Address: What interest(s) to be covered $ Name of Individual: Address: What interest(s) to be covered $ 5

Partnership: Name and Address of Partners: Name and Address of Partners: Name and Address of Partners: Name and Address of Partners: Family Corp. Yes No Names and address of each member, percent owned and titles. (Is each member engaged in the farming operation?) $ Snowmobiles Describe each unit by Make, Model and Serial No. $ ATV Describe each unit by Make, Model and Serial No. $ Outboard Motors (25 H.P. or less no charge) List ea. unit by Make, Model and H.P. $ Inboard Motors MPH $ Medical Payments Person Named: (Only available in AZ, DE, IA, MN, MO, NE, OH, PA, WA, WY) Ages 10-70 Name Age Relationship $ Maximum Name Age Relationship $ Limit Name Age Relationship $ $1,000 Name Age Relationship $ Type of Business Pursuits Incidental Business Receipts $ Animal Collision - # of head $ Increased limits for borrowed or rented equipment, (amount over $25,000) minimum of 6 months Cov. $ Hunting and Fishing total annual receipts $ $ Lodging and meals provided? Yes No $ Fire Legal Liability in excess of $50,000? $ $ COVERAGE FOR EQUINE LIABILITY AVAILABLE. MUST COMPLETE SUPPLEMENTAL EQUINE LIABILITY APPLICATION. EQUINE LIABILITY INCLUDES ANY BOARDING, BREEDING, TRAINING, SALES AND SHOWS OF OWNED AND NON-OWNED HORSES. DESIRE CARE, CUSTODY AND CONTROL POLICY FOR NON-OWNED HORSES? Yes No COMPLETE SUPPLEMENTAL APPLICATION. IS COMMERCIAL EXCESS LIABILITY DESIRED? Yes No LIMITS AVAILABLE: $1,000,000, $2,000,000 OR $3,000,000. MUST COMPLETE EXCESS APPLICATION. CANNOT BE BOUND What are the principal products of the farm? Has this changed in the past 3 years? Yes No Is any business other than farming conducted on the premises? (Explain) Does insured have another occupation besides farming? Yes No If yes, explain Does anyone other than the owner or insured have an interest in the property? If yes, list names and interest: If tenant, does American Reliable Insurance have coverage for owner? If yes, give policy number: (If leased land, leasee must provide proof of insurance.) If absentee owner, does American Reliable Insurance have coverage for tenant? If yes, give policy number: Is there other property or liability insurance on this farm? If yes, give name of company and explain what is covered: Has the insured been cancelled or refused renewal in last 5 years? (Not applicable in Missouri.) If yes, explain: Describe and list amounts of all losses during past 3 years: Repaired? Yes No Have these losses been verified? Yes No Name of previous carrier Policy # of previous carrier: If no prior carrier explain: Has this account been written by your agency previously? How long? Time you have known insured? Is there an airplane landing strip on your premises? Is it filed with the FAA? Are all insured buildings being utilized for the purpose intended? Are any buildings in need of repair? Explain Does Roof Exclusion apply? To what building(s)? 6

Are all dwellings occupied full-time? If not, explain exceptions: Are mobile homes to be covered? If yes, complete a mobile home application. Give year of mobile home: Are there any lakes, ponds, swimming pools, or other recreational facilities situated on any insured location? If yes, is it open to public? Are swimming pools completely fenced in (attach photo)? Are there any diving boards? Are there any trampolines? Are any confinement buildings being insured? If yes, attach completed confinement questionnaire. Does applicant have horses? Used for? If yes, attach EQUINE application. Is there boarding or off-premises exposures? Yes No If pleasure, give use Does applicant have dogs? Yes No # and Breed Does applicant have exotic animals on premises? Yes No Explain: What fire protection equipment is employed in buildings or major machinery? Are there Beauty Shop/Tanning business or Babysitting on property? Yes No Explain: Are all livestock areas fenced? Condition of fences? Are there any fuel tanks or wood stoves located inside outbuildings? Are any wood burning stoves or devices used in dwelling(s)? Yes No Type of fences? If yes, attach completed wood stove application and picture. If yes, attach completed wood stove application and picture. Primary source of heat? Yes No (If yes, do not bind) Including Fireplaces MINE SUBSIDENCE: APPLICATION MUST BE SIGNED BY INSURED AND PRODUCER If Illinois, Indiana, Kentucky, West Virginia or Ohio risk, is Mine Subsidence Coverage desired? Yes No If yes, what items? If Mine Subsidence Coverage is not desired, Insured must waive in writing: I do not desire Mine Subsidence Coverage. Insured Signature Date TERRORISM COVERAGE DESIRED: Yes No (See Attached Disclosure) Insured Signature Date Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subject such person to criminal and civil penalties. I/We understand and agree that any misstatement of warranty or fact on this application shall be considered a violation of coverage afforded under any policy issued on the basis of this application. The insured assigns as security for the total premium and/or fees payable any and all unearned premiums which may become payable. I/We agree to pay reasonable attorneys fees, costs and expenses necessarily incurred if suit or collection becomes necessary. Applicant s Signature Date PRODUCER INFORMATION Agency: Agency Code # License # Date Agent s Signature SS# Date: Mail, Email or Fax Application to: Allen Financial Insurance Group P.O. Box 9957 Phoenix, AZ 85068 (602) 992-1570 FAX (602) 992-8327 email: ballen@eqgroup.com Website: www.eqgroup.com 7

American Bankers Insurance Company APPLICATION FOR LEGAL LIABILITY OF NONOWNED HORSES IN YOUR CARE, CUSTODY OR CONTROL AGENCY NAME ADDRESS AGENCY CODE ODQ6 - TELEPHONE NO. FAX NO. Email THIS IS NOT A BINDER DIRECT BILL NEW BUSINESS DESIRED EFFECTIVE DATE ACCOUNT CURRENT RENEWAL EXPIRATION DATE POLICY NO. CCC IMPORTANT: INCOMPLETE AND UNSIGNED APPLICATIONS WILL BE RETURNED FOR COMPLETION. NAME OF INSURED BUSINESS/STABLE NAME MAILING ADDRESS CITY/STATE/ZIP CODE LOCATION OF ACTUAL OPERATIONS IF OTHER THAN MAILING ADDRESS TELEPHONE NO. ( ) CITY/STATE/ZIP CODE IF CORPORATION, LIST ALL OFFICERS AND DIRECTORS. IF PARTNERSHIP, LIST ALL PARTNERS. A SEPARATE APPLICATION FOR THE INFORMATION THAT FOLLOWS WILL BE REQUIRED FOR EACH LOCATION. DO YOU: HOW LONG HAS INSURED OR MANAGER BEEN IN THIS BUSINESS? YEARS. OWN IF LESS THAN THREE YEARS, BRIEFLY DESCRIBE RELATED EXPERIENCE. LEASE RENT THE PREMISES? IF LEASED/RENTED, WHO IS RESPONSIBLE FOR FENCE REPAIR? IF LEASED/RENTED, WHO IS RESPONSIBLE FOR BUILDING REPAIR? DESCRIBE TYPE OF FENCING USED IN RUNS, PASTURES, PADDOCKS: DESCRIBE CONDITION OF FENCES: EXCELLENT GOOD FAIR POOR DESCRIBE CONDITION OF STABLES: EXCELLENT GOOD FAIR POOR OPERATIONS: STABLE OWNER BOARDING BREEDING TRAINING OTHER BREED OF ANIMALS USE OF ANIMALS DESCRIBE TYPE OF SECURITY/SUPERVISION OF STABLES ARE FIRE EXTINGUISHERS ACCESSIBLE AND OPERABLE IN EACH STABLE? YES NO IS ANY STABLE OVER 25 YEARS OLD? YES NO IF YES, WHEN WAS THE LAST TIME ELECTRICAL WIRING WAS CHECKED, CERTIFIED SAFE, AND SUITABLE FOR CURRENT USAGE? 8

CARE, CUSTODY OR CONTROL PROGRAM NUMBER OF STALLS: BARN #1 BARN #2 BARN #3 BARN #4 MINIMUM NUMBER OF HORSES IN YOUR CARE AVERAGE NUMBER OF HORSES IN YOUR CARE MAXIMUM NUMBER OF HORSES IN YOUR CARE MINIMUM VALUE OF HORSES IN YOUR CARE AVERAGE VALUE OF HORSES IN YOUR CARE MAXIMUM VALUE OF HORSES IN YOUR CARE SELECT APPROPRIATE LIMITS OF LIABILITY FROM THE OPTIONS OUTLINED ON PAGE 3. POLICY COVERS INCIDENTAL TRANSPORTATION ONLY, UP TO 150 MILES FROM INSURED S LOCATION. *COVERAGE MAY BE EXTENDED. REFER TO UNDERWRITER FOR PREMIUM. DO YOU TRANSPORT HORSES FOR OTHERS? YES NO IF YES, MAXIMUM NUMBER OF TRIPS PER YEAR MAXIMUM NUMBER OF ANIMALS PER TRIP RADIUS OF NORMAL OPERATIONS miles NUMBER OF TRIPS AND DESTINATIONS EXCEEDING NORMAL 150 MILE RADIUS HOW OFTEN ARE TRAILER OR VAN FLOOR BOARDS CHECKED ARE FIRE EXTINGUISHERS CARRIED ON VAN OR TRUCK? YES NO DO AT LEAST TWO PEOPLE GO ON EACH TRIP? YES NO DESCRIBE ANY LOSSES OR POTENTIAL CLAIMS IN THE PAST THREE YEARS AND INCLUDE DEATHS OF ANY ANIMAL(S) IN YOUR CUSTODY, EVEN IF A CLAIM WAS NOT PRESENTED FRAUD NOTICES Standard: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties. Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. APPLICANT (PRINT) SIGNATURE x AGENT SIGNATURE x DATE DATE I understand that the insurance being applied for, if accepted by the Company, will be based on the statements made in this application. If information is withheld or falsely stated, any insurance issued may be subject to rescission or modification as provided by the law of the state in which the application was accepted or the policy issued. Limit Per Horse American Bankers Insurance of Florida CARE, CUSTODY OR CONTROL PROGRAM RATES AND LIMITS OF LIABILITY (CHECK ONE) Maximum Loss Per Policy Year Policy Premium Up to 20 Horses Additional Charge Each Horse Over 20 Company Code $200,000 $500,000 $2,500 $20 01 $150,000 $400,000 $2,250 $20 13 $100,000 $300,000 $1,500 $20 02 $75,000 $300,000 $1,300 $20 14

$50,000 $250,000 $900 $20 03 $25,000 $250,000 $550 $20 04 $15,000 $150,000 $500 $10 15 $10,000 $100,000 $400 $10 05 $10,000 $50,000 $350 $10 06 $5,000 $50,000 $300 $10 07 $5,000 $25,000 $250 $10 08 $2,500 $25,000 $200 $10 16 Policy Premium Up to 10 Horses Additional Charge 11-19 Horses, Each $2,500 $12,500 $175 $5 17 $5,000 $20,000 $200 $5 18 Base Premium (from above) + ( Number of Horses over 20 x ) Additional Premium for Each Horse = $ ANNUAL PREMIUM Transportation Extension $ (*Refer to Underwriter) Rates subject to change. TOTAL ANNUAL PREMIUM $