PRODUCER PHONE (A/C, No, Ext): FAX (A/C, No): CODE: AGENCY CUSTOMER ID INDICATE SECTIONS ATTACHED AGRICULTURE APPLICATION APPLICANT INFORMATION SECTION COMPANY (866)386-4136 x2419 (601)898-4793 Continental Brokers, Inc. 214 Key Drive Suite 2000 Madison MS 39110 00006869 SUB CODE: COMPANY POLICY OR PROGRAM NAME NEW RNWL QUOTE BOUND (DATE): PROGRAM CODE: EFFECTIVE DATE EXPIRATION DATE PAYMENT PLAN DIRECT BILL ISSUE POLICY POLICY TYPE AGENCY BILL ACCOUNT NO. DATE (MM/DD/YYYY) 1/24/2008 NAIC CODE DEPOSIT PROPERTY SCHEDULED/UNSCHEDULED AGRI-PERSONAL PROPERTY AGRI-BUSINESS LIABILITY APPLICANT INFORMATION NAME (First Named Insured & Other Named Insureds) COMMERCIAL GENERAL LIABILITY AUTO UMBRELLA FEDERAL ID # PERSONAL INLAND MARINE MAILING ADDRESS (of First Named Insured) PHONE (A/C, No, Ext): INDIVIDUAL PARTNERSHIP CORPORATION TYPE OF FARM/RANCH FIELD CROPS FRUITS VEGETABLES DAIRY JOINT VENTURE OTHER DATE BUS. STARTED MUSHROOMS NUTS FLOWERS VINEYARDS SIC Code DESCRIBE FARM/RANCH OPERATIONS AND ANY INCIDENTAL BUSINESS ACTIVITIES GREENHOUSES NURSERY STOCK SOD WORMS E-MAIL ADDRESS: CONTACT BEES FUR BEARING ANIMALS LIVESTOCK-TYPE: PHONE (A/C, No, Ext): TOBACCO POULTRY PREMISES INFORMATION LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP CODE (Include route, section, township, range, etc. if necessary) PROT CLASS # ACRES # ACRES CULTIVATED # ACRES IN PASTURE FARMED BY GROSS RECEIPTS LOSS HISTORY ENTER ALL CLAIMS OR OCCURRENCES FOR THE PAST FIVE YEARS DATE OF OCCURRENCE TYPE OF LOSS DESCRIPTION OF OCCURRENCE AMOUNT PAID PRIOR INSURANCE INFORMATION PRIOR CARRIER TYPE OF INSURANCE POLICY # AMOUNT OF COVERAGE REMARKS ACORD 401 (2001/10) ACORD CORPORATION 1995 INS401 (0110).02a Page 1 of 2
GENERAL INFORMATION 1. DOES APPLICANT HAVE ANY OTHER BUSINESS? (IF YES, DESCRIBE) 2. HAS INSURANCE BEEN TRANSFERRED WITHIN THE AGENCY? 3. HAS ANY POLICY BEEN CANCELLED OR NONRENEWED IN THE PAST 5 YEARS? IF YES, EXPLAIN. (NOT APPLICABLE IN MO) 4. DATE OF LAST INSPECTION: 5. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (In Ri, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) GENERAL INFORMATION - LIABILITY ONLY YES NO EXPLAIN ALL "YES" RESPONSES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. IS THERE AN AIRSTRIP ON THE PREMISES? 11. 12. ARE INDEPENDENT CONTRACTORS HIRED TO PERFORM ANY FARMING OPERATIONS? IS ANY PART OF THE FARM USED OR LEASED FOR ORGANIZED RECREATIONAL USE? DOES APPLICANT BUILD, REPAIR OR DESIGN MACHINERY, EQUIPMENT OR SYSTEMS FOR ANYONE AT A CHARGE OR FEE? DOES APPLICANT MIX, PROCESS, SLAUGHTER, BUTCHER OR OTHERWISE PREPARE FOR ANY "END CONSUMER" HIS OR ANY OTHER GROWER'S PRODUCT? DOES APPLICANT HANDLE ANY PRODUCT, SUCH AS SEED, FERTILIZER, SPRAYS, ETC. FOR RESALE? ARE ANY CONTRACT OR SERVICE OPERATIONS PERFORMED FOR OTHERS SUCH AS SNOW REMOVAL, TILLING, EXCAVATING OR DITCHING? ARE THE FARM PREMISES OPEN TO THE PUBLIC FOR ACTIVITIES SUCH AS ROADSIDE STANDS, "U-PICK", RECREATIONAL, "RENT-A-GARDEN", AUCTION, SALES, SHOW, FOOD OR BEVERAGE SERVICE, HAY RIDES, FISHING, KENNELS, ANIMAL BOARDING, OR CHRISTMAS TREE SALES USES? ARE ANY PORTIONS OF THE FARM RENTED OR LEASED OR USED BY ANY OTHER INDIVIDUAL, CORPORATION OR INTEREST FOR OTHER THAN FARMING? IS THERE ANY UNUSUAL HAZARD SUCH AS (BUT NOT LIMITED TO) OPEN DUMP PITS, SILAGE PITS, SUMP HOLES, PONDS, LAKES OR RESERVOIRS? ARE ANY "HOLD HARMLESS" OR "INDEMNIFYING" AGREEMENTS IN EFFECT? IF LIVESTOCK IS KEPT, ARE ALL AREAS ADEQUATELY FENCED AND ARE FENCES IN A GOOD STATE OF REPAIR? IF NO, PLEASE EXPLAIN. PREMISES IS IN: OPEN RANGE AREA CLOSED RANGE AREA REMARKS EXPLAIN ALL "YES" RESPONSES 13. 14. ANY NON-OWNED HORSES ON ANY INSURED PREMISES? 15. DOES INSURED BOARD, RACE, BREED OR RENT HORSES? 16. 17. 18. IF DAIRY FARM, IS THERE ANY PROCESSING OF MILK? 19. IF DAIRY FARM, IS THERE ANY RETAIL RECEIPTS SALES OF MILK PRODUCTS TO PUBLIC? 20. NUMBER OF COWS MILKED 21. ARE ANY PREMISES USED FOR HUNTING PURPOSES? 22. ARE THE DESCRIBED INSURED PREMISES THE ONLY PREMISES WHICH THE APPLICANT OR SPOUSE OWNS, RENTS OR OPERATES AS A FARM OR RANCH, OR MAINTAINS AS A RESIDENCE, OTHER THAN BUSINESS PROPERTY? IF NO, EXPLAIN. IS ANY LAND HELD FOR REAL ESTATE DEVELOPMENT OR SPECULATION? DOES APPLICANT MAINTAIN ANY VACATION OR SEASONAL PREMISES? BY OWNERS: NO CHARGE FEE 23. IS THERE A SWIMMING POOL ON PREMISES? 24. DOES APPLICANT SERVE ON ANY BOARDS FOR REMUNERATION? ATTACHMENTS PHOTOS BILL OF SALE RENTED TO OTHERS: RECEIPTS DOES APPLICANT MAINTAIN A NON-FARM OFFICE OR PRIVATE SCHOOL IN AN INSURED BUILDING? IF YES, IS IT FENCED? IS THERE A DIVING BOARD? 25. IS THE APPLICANT A SUBSIDIARY OF ANOTHER? 26. DOES THE APPLICANT HAVE SUBSIDIARIES? 27. IS A FORMAL SAFETY PROGRAM IN EXISTENCE? 28. DOES APPLICANT HAVE ANY POTENTIALLY DANGEROUS ANIMALS OR EXOTIC PETS? 29. IS THERE ANY WATERCRAFT OR SNOWMOBILE EXPOSURE? STATE SUPPLEMENT(S) (If applicable) PREMISES DIAG. APPRAISALS INVENTORIES NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied) APPLICANT'S SIGNATURE PRODUCER'S SIGNATURE ACORD 401 (2001/10) INS401 (0110).02a Page 2 of 2
PRODUCER AGRICULTURE LIABILITY SECTION (866)386-4136 x2419 Continental Brokers, Inc. 214 Key Drive Madison MS 39110 NAMED INSURED/APPLICANT'S NAME COMPANY ACCOUNT NUMBER DATE 1/24/2008 CODE: SUBCODE: AGENCY CUSTOMER ID 00006869 COVERAGES BODILY INJURY AND PROPERTY DAMAGE LIABILITY PERSONAL AND ADVERTISING INJURY LIABILITY MEDICAL PAYMENTS PROPERTY DAMAGE LIABILITY FIRE DAMAGE LIMIT ADDITIONAL COVERAGE -- DAMAGE TO PROPERTY OF OTHERS POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE NEW RNWL LIMITS OF LIABILITY EACH "OCCURRENCE" LIMIT GENERAL AGGREGATE LIMIT EACH "OCCURRENCE" LIMIT GENERAL AGGREGATE LIMIT ANY ONE PERSON LIMIT EACH "OCCURRENCE" LIMIT ANY ONE FIRE NAME OF INSURED(S) AAIS PERSONAL LIABILITY COVERAGE COMMERCIAL GENERAL LIABILITY YES CODE LOC. # NO INITIAL FARM PREMISES IF YES, COMPLETE COMMERCIAL GENERAL LIABILITY APPLICATION COVERAGE NOT MORE THAN ACRES ADDITIONAL FARM PREMISES MAINTAINED BY NAMED INSURED FARM PERSONAL LIABILITY (AAIS) YES LOC # NO INCR LIMITS FACTOR FARM COMMERCIAL LIABILITY (AAIS) BASIS/RATE PREMIUM ADDITIONAL NON-FARM PREMISES OCCUPIED BY INSURED LOC # SEASONAL PERMANENT ADDITIONAL RESIDENCE RENTED TO OTHERS # FAMILIES LOC # CUSTOM FARMING RECEIPTS (RATE PER 1,000) ROADSIDE STANDS -- FARM PRODUCTS PRINCIPALLY ON THE INSURED FARM (RATE PER 1,000 GROSS SALES) DAY CARE COVERAGE (HOME) 1-3 PERSONS 1-6 PERSONS LIMITED FARM POLLUTION LIABILITY (REFER TO COMPANY) RECEIPTS SALES CONTINGENT LIABILITY FOR CROP DUSTING BY INDEPENDENT AIRCRAFT (RATE PER 1,000 COST) DOMESTIC WORKERS' COMP ANIMAL COLLISION EMPLOYERS LIABILITY # FULL TIME EMPLOYEES COST INSERVANT OUTSERVANT # PART TIME EMPLOYEES LIMIT # OF RESIDENTIAL EMPLOYEES LIMIT PER HEAD # OF HEAD PAYROLL OTHER: ACORD 404 (2000/05) ATTACH TO AGRICULTURE APPLICATION ACORD CORPORATION 1995 INS404 (0008).01a Page 1 of 2
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOSS PAYEE LOCATION: VEHICLE: BUILDING: BOAT: MORTGAGEE LIENHOLDER SCHEDULED ITEM NUMBER: OTHER EMPLOYEE AS LESSOR ITEM DESCRIPTION: REMARKS ACORD 404 (2000/05) INS404 (0008).01a Page 2 of 2
AGRICULTURE PREMISES DIAGRAM ATTACH TO ACORD 401 DATE 1/24/2008 PRODUCER (866)386-4136 x2419 Continental Brokers, Inc. 214 Key Drive Madison MS 39110 CODE: AGENCY CUSTOMER ID 00006869 PREMISES INFORMATION DIAGRAM # LOCATION # SUB CODE: NAMED INSURED/APPLICANT'S NAME COMPANY POLICY NUMBER PHONE NUMBER ACCOUNT NUMBER PREMISES ADDRESS (FROM ACORD 401, INCLUDE ROUTE, SECTION, TOWNSHIP, RANGE, ETC. IF NECESSARY) NOTES (HOW TO GET THERE, NEAREST CROSS STREET, ETC.): PREMISES DIAGRAM SHOW ALL BUILDINGS ON THE PREMISES (WHETHER INSURED OR NOT) AND DISTANCE IN FEET BETWEEN THEM. LABEL ALL BUILDINGS AND ATTACH DATED PHOTOGRAPH OF EVERY BUILDING. (INDICATE "NC" IF NOT COVERED) N O R T H W E S T E A S T S O U T H ACORD 405 (2000/05) ATTACH TO AGRICULTURE APPLICATION ACORD CORPORATION 2000 INS405 (0008)a
PRODUCER CODE: AGENCY CUSTOMER ID GENERAL INFORMATION AGRICULTURE PROPERTY SECTION SCHEDULED AND UNSCHEDULED PERSONAL PROPERTY (866)386-4136 x2419 Continental Brokers, Inc. 214 Key Drive Madison MS 39110 00006869 SUBCODE: NAMED INSURED/APPLICANT'S NAME COMPANY ACCOUNT NUMBER POLICY NUMBER NEW EFFECTIVE DATE EXPIRATION DATE 1. IS ANY PROPERTY KEPT ON A LOCATION(S) OTHER THAN AN INSURED LOCATION? IF YES, WHERE IS IT KEPT... (A) DURING FARMING SEASON? (B) DURING OFF SEASON? RNWL DATE 1/24/2008 2. WHAT IS MAXIMUM VALUE OF EQUIPMENT AT ANY ONE LOCATION... (A) DURING FARMING SEASON? (B) DURING OFF SEASON? INSIDE IN OPEN INSIDE IN OPEN 3. IS THERE ANY EQUIPMENT LOANED OR RENTED TO/FROM OTHERS? IF YES, VALUE FOR BORROWED OR RENTED EQUIPMENT: 4. WHAT IS RADIUS OF OPERATIONS OF EQUIPMENT? 5. IS EQUIPMENT WELL MAINTAINED? MILES SCHEDULED FARM PERSONAL PROPERTY DESCRIPTION (INC YR, MAKE, MODEL & SERIAL # ; LIVESTOCK INFO, CUSTOM USE, ETC) CAUSE OF LOSS (PERILS) COINS % DEDUCTIBLE LIMIT OF INSURANCE PREMIUM 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 1. 2. PEAK SEASON: TIME PERIOD FROM: TO N/A N/A TRANSIT HAY IN OPEN HAY IN BUILDINGS MISCELLANEOUS AGRICULTURAL MACHINERY AND IMPLEMENTS MISCELLANEOUS TOOLS, EQUIPMENT AND SUPPLIES STACK STACK SCHEDULED HAY LOCATED OFF PREMISES 1. NOT EXCEEDING MAXIMUM CLEAR SPACE FT MAXIMUM CLEAR SPACE FT PER ITEM NOT EXCEEDING PER ITEM CAUSE OF LOSS (PERILS) COINS % DEDUCTIBLE LIMIT OF INSURANCE PREMIUM LOCATION DESCRIPTION (INCLUDE ADDRESS AND STACK NUMBER) CAUSE OF LOSS (PERILS) COINS % DEDUCTIBLE LIMIT OF INSURANCE PREMIUM CAUSE OF LOSS (PERILS) COINS % DEDUCTIBLE LIMIT OF INSURANCE PREMIUM 2. 3. 4. ACORD 403 (2000/05) ATTACH TO AGRICULTURE APPLICATION ACORD CORPORATION 1995 INS403 (0008).01a Page 1 of 3
AGRICULTURE UNSCHEDULED FARM PERSONAL PROPERTY AGRICULTURAL AGRICULTURAL # OF UNIT CAUSE COINS MACHINERY AND # OF UNIT CAUSE COINS PRODUCE DED PREMIUM UNITS PRICE VALUE OF LOSS % IMPLEMENTS UNITS PRICE VALUE OF LOSS % DED PREMIUM BARLEY CORN FODDER FRUIT GROUND FEED HAY TILLAGE: TRACTORS DISCS HARROWS PLOWS OTHER MFG STK FEED NUTS OATS SILAGE SOYBEANS STRAW WHEAT CULTIVATING: CULTIPACKERS CULTIVATORS DRILLS PLANTERS ROTARY HOES SEEDERS SPREADERS SPRAYERS VALUE: PREMIUM: # OF UNIT CAUSE COINS POULTRY DED PREMIUM BIRDS PRICE VALUE OF LOSS % CHICKENS TURKEYS HARVESTING: AUGERS BLOWERS CHOPPERS COMBINES CORN PICKERS COTTON PCKRS DRIERS VALUE: PREMIUM: ELEVAT (PORT) # OF UNIT CAUSE COINS LIVESTOCK DED PREMIUM HEAD PRICE VALUE OF LOSS % DAIRY COWS DAIRY HEIFERS DAIRY CALVES BEEF COWS BEEF CALVES FEEDER CATTLE BULLS SOWS & GILTS BOARS FEEDER PIGS EWES RAMS LAMBS HORSES PONIES FORAGE HARVESTERS GRAIN CLNRS GRAIN HEADS GRAPE HARVESTERS HAY BALERS MOWERS NUTSHAKERS RAKES RICE HARVSTRS ROODS SILO FILTERS SILO UNLOADRS TOMATO HARVESTERS WAGONS MULES VALUE: ACORD 403 (2000/05) INS403 (0008).01a PREMIUM: VALUE: PREMIUM: Page 2 of 3
AGRICULTURAL TOOLS, EQUIPMENT AND SUPPLIES AGRICULT CHEM FERTILIZERS HERBICIDES INSECTICIDES PESTICIDES AIR COMPRESSORS BINS AGRICULTURE UNSCHEDULED FARM PERSONAL PROPERTY # OF UNIT CAUSE COINS # OF UNIT CAUSE COINS DED PREMIUM IRRIGATION UNITS PRICE VALUE OF LOSS % EQUIPMENT UNITS PRICE VALUE OF LOSS % DED PREMIUM CENTER PIVOT IRR DRIP HANDSET LATERAL MOVE IRR PUMPS SOLID SET WHEEL-LINE BOXES & BOX SHOOK ELECTRIC MOTORS FARM LUBRICANTS FENCING & POSTS GASOLINE/DIESEL FUEL HAND TOOLS VALUE: PREMIUM: MATERIALS & SUPP MILKING EQUIP # OF UNIT CAUSE COINS UNITS PRICE VALUE OF LOSS % DED PREMIUM OFFICE EQUIP PAINTS PICKING EQUIP POULTRY EQUIP POWER TOOLS SADDLES & TACK SPARE PARTS TIRES VET SUPPLIES WELDRS & TRCHES VALUE: PREMIUM: VALUE: PREMIUM: IF EXCLUSION OF PROPERTY FROM BLANKET COVERAGE IS DESIRED, PLEASE LIST THE SPECIFIC ITEMS LIMITS OF INSURANCE ITEMS AGRICULTURAL PRODUCE POULTRY LIVESTOCK AGR MACHINERY & IMPLEMENTS AGR TOOLS, EQUIP & SUPPLIES IRRIGATION EQUIPMENT x RATE = PREMIUM REMARKS ACORD 403 (2000/05) INS403 (0008).01 Page 3 of 3
PRODUCER AGRICULTURE PROPERTY SECTION (866)386-4136 x2419 Continental Brokers, Inc. 214 Key Drive Madison MS 39110 NAMED INSURED/APPLICANT'S NAME COMPANY ACCOUNT NUMBER DATE (MM/DD/YYYY) 1/24/2008 CODE: AGENCY CUSTOMER ID 00006869 PREMISES INFORMATION LOCATION # BUILDING # SUBCODE: POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE NEW STREET, CITY, COUNTY, STATE, ZIP CODE (Include route, section, township, range, etc if necessary; address should be same as shown on ACORD 401) RNWL FARM NAME SUBJECT OF INSURANCE VALUATION RC/ACV COINS % CAUSE OF LOSS DEDUCTIBLE VALUE LIMIT OF INSURANCE PREMIUM ADDITIONAL COVERAGES, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION BLDG TYPE DIAG # CONST TYPE DISTANCE TO HYDRANT FIRE STAT FIRE DISTRICT/CODE NUMBER PROT CLASS YR BUILT HEAT TYPE ROOF YEAR AREA PREMISES GENERAL INFORMATION 1. IS THERE A YEAR-ROUND WATER SUPPLY USABLE FOR FIRE PROTECTION? IF YES, (A) SOURCE= (B) QUANTITY = FT MI 2. ARE ANY WOOD OR COAL FIRED STOVES USED IN ANY BUILDINGS? IF YES, EXPLAIN YES NO YES NO WELL POND/LAKE HYDRANT WITHIN 1,000 FT. OTHER: LESS THAN 1,000 GALLONS 1,000-3,000 GALLONS OVER 3,000 GALLONS 3. ARE ANY BURGLARY AND/OR FIRE ALARMS ON THE PREMISES? IF YES, TYPE OF ALARM INDICATE FLOORS PROTECTED BY ALARM: DIAGRAM #: 5. IS ENTIRE PREMISES OCCUPIED YEAR ROUND? PREMISES INFORMATION LOCATION # BUILDING # 4. DOES APPLICANT PERFORM MAINTENANCE ON EQUIPMENT? IF NO, PLEASE INDICATE TYPE OF REPAIRS DONE, WHERE PERFORMED AND BY WHOM STREET, CITY, COUNTY, STATE, ZIP CODE (Include route, section, township, range, etc if necessary; address should be same as shown on ACORD 401) FARM NAME SUBJECT OF INSURANCE VALUATION COINS CAUSE LIMIT RC/ACV % OF LOSS DEDUCTIBLE VALUE OF INSURANCE PREMIUM ADDITIONAL COVERAGES, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION BLDG TYPE DIAG # CONST TYPE DISTANCE TO FIRE DISTRICT/CODE NUMBER PROT CLASS YR BUILT HEAT TYPE ROOF YEAR AREA HYDRANT FIRE STAT FT MI ACORD 402 (2001/10) ATTACH TO AGRICULTURE APPLICATION ACORD CORPORATION 1995 INS402 (0110).04a Page 1 of 2
PREMISES GENERAL INFORMATION 1. IS THERE A YEAR-ROUND WATER SUPPLY USABLE FOR FIRE PROTECTION? 2. ARE ANY WOOD OR COAL FIRED STOVES USED IN ANY BUILDINGS? IF YES, (A) SOURCE= (B) QUANTITY = IF YES, EXPLAIN YES WELL LESS THAN 1,000 GALLONS NO POND/LAKE 1,000-3,000 GALLONS HYDRANT WITHIN 1,000 FT. OTHER: OVER 3,000 GALLONS 3. ARE ANY BURGLARY AND/OR FIRE ALARMS ON THE PREMISES? 4. DOES APPLICANT PERFORM MAINTENANCE ON EQUIPMENT? IF YES, TYPE OF ALARM INDICATE FLOORS PROTECTED BY ALARM: DIAGRAM #: 5. IS ENTIRE PREMISES OCCUPIED YEAR ROUND? IF NO, PLEASE INDICATE TYPE OF REPAIRS DONE, WHERE PERFORMED AND BY WHOM PREMISES INFORMATION LOCATION # BUILDING # STREET, CITY, COUNTY, STATE, ZIP CODE (Include route, section, township, range, etc if necessary; address should be same as shown on ACORD 401) FARM NAME SUBJECT OF INSURANCE VALUATION COINS CAUSE DEDUCTIBLE VALUE LIMIT RC/ACV % OF LOSS OF INSURANCE PREMIUM ADDITIONAL COVERAGES, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION BLDG TYPE DIAG # CONST TYPE DISTANCE TO FIRE DISTRICT/CODE NUMBER PROT CLASS YR BUILT HEAT TYPE ROOF YEAR AREA HYDRANT FIRE STAT PREMISES GENERAL INFORMATION ADDITIONAL INTERESTS RANK: NAME AND ADDRESS EVIDENCE RANK: NAME AND ADDRESS EVIDENCE INTEREST LOSS PAYEE MORT- GAGEE REMARKS FT MI 1. IS THERE A YEAR-ROUND WATER SUPPLY USABLE FOR FIRE PROTECTION? 2. ARE ANY WOOD OR COAL FIRED STOVES USED IN ANY BUILDINGS? IF YES, (A) SOURCE= (B) QUANTITY = IF YES, EXPLAIN YES WELL LESS THAN 1,000 GALLONS NO POND/LAKE 1,000-3,000 GALLONS HYDRANT WITHIN 1,000 FT. OTHER: OVER 3,000 GALLONS 3. ARE ANY BURGLARY AND/OR FIRE ALARMS ON THE PREMISES? 4. DOES APPLICANT PERFORM MAINTENANCE ON EQUIPMENT? IF YES, TYPE OF ALARM INDICATE FLOORS PROTECTED BY ALARM: DIAGRAM #: 5. IS ENTIRE PREMISES OCCUPIED YEAR ROUND? CERTIF- ICATE POLICY IF NO, PLEASE INDICATE TYPE OF REPAIRS DONE, WHERE PERFORMED AND BY WHOM INTEREST LOSS PAYEE MORT- GAGEE CERTIF- ICATE POLICY ACORD 402 (2001/10) INS402 (0110).04a Page 2 of 2