FARMERS MUTUAL INSURANCE COMPANY OF NODAWAY COUNTY P O BOX 394 - 311 EAST SUMMIT DRIVE – MARYVILLE MO 64468

APPLICATION

Renewal of #_________________ Policy #________________ Agent #________________

(Policy Term: 12:01 A.M. Standard time at location of property)

Effective Expires

Named Insured______________________________________________________ SSN_________________ DOB________________ Occupation_________________________________________________ Dependents_____ Ages____________ Marital Status ______ Spouse/Co-Insured___________________________________________________ SSN________________ DOB_________________ Occupation_________________________________________________ Dependents_____ Ages____________ Marital Status ______ Relationship to 1st named insured_______________________________________________________________________________ Address_____________________________________________ City_____________________________ State_______ Zip_________ Home #_____________________ Cell #____________________ Work #___________________ Other #_________________

1st Mortgage 2nd Mortgage Address Address City State Zip City State Zip Loan # (s) Escrow Loan # (s)

Deductible Credits $500 (w/$1,000 min wind & hail) $1,000 $1,500 $2,500 $5,000 HO's N/A 0% 10% 20% 25%

FL 2/3 N/A 0% 10% 20% 25% FEC's 0% 10% 15% 20% 25%

Annual Semi-Annual Quarterly Monthly Cr it Card Monthly & Credit Card Payments require Authorization Forms * Monthly Payments - Checking Account: VOIDED CHECK * Savings Account: DEPOSIT SLIP ============================================================================================== FORM 2 FL2 ELITE PREFERRED SELECT FL 1 FORM 3 FL3 ELITE RENTAL CHOICE FL 502 FL 6 Coverage A - Dwellings

Loc. Description Cov. Limit Rate W x L Roof-Type/ Age

Yr. Blt.

Cond. P Class

Brick/ Frame

Premium

$ $ $ $ $ $ $__________________ Market Value ______ Miles from ___________________ Fire Department (NOTE: Homeowners risks written for less than 80% of the total residence replacement cost will not be accepted. If 5 acres or less at the dwelling premises and outbuildings are to be excluded, Form FL-304 must be completed, signed and attached.)

Coverage B – Other Structures (In Town) Loc. Structures Cov. Limit Rate W x L Roof-Type/

Age Yr. Blt.

Cond. Premium

$ $ $ $ $ $

Coverage C – Personal Property Coverage D – Loss of Use

Loc. Cov. Limit Rate Premium $ $ $

Loc. Cov. Limit Rate Premium $ $ $ $ Replacement Costs $

Premium

Multi-Policy Discount: A, B, C, D (Prem) $ New Home Discount $ Total Premium Page 1: $

Comments: _______________________________________ _________________________________________________ _________________________________________________ _________________________________________________

FMAPP 1

Coverage E – Outbuildings (Out of Town) Loc. Structures Cov. Limit Rate W x L Roof-Type/

Age Yr. Blt.

Cond. Premium

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Coverage F – Scheduled Farm Property Item Cov. Limit Rate Year Make Model Ser. # Premium

Farm Machinery $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Livestock $ $ $ $ $ $ $ $ $ $ Hay $ $ $ $ $ $ Pump/Ant. Charge $ $ $ $ Other $ $ $ $

Coverage G – Unscheduled Farm Personal Property (See Attachment) Coverage Limit Percent Rate Premium

$ (100%) ----- N/A $ (80%) $

Coverage H – Commercial Structures Loc. Structure Cov. Limit Rate W x L Roof-Type/

Age Yr. Blt.

Cond. Premium

$ $ $ $ $ $ $ $

Premium

Comments: ____________________________________ Commercial/Builder Risk Theft $ Other $ Credits $ Earth Quake $ Inland Marine $ Total Premium Page 1 & 2: $

______________________________________________ ______________________________________________ ______________________________________________

FMAPP 01/13 2

LIABILITY

Personal Liability Farm Liability 0-10 Acres (No Livestock) Country Home (less than 40 Acres) Incidental Farming (11-40 Acres &/or 2 head of Livestock or less) Livestock No Livestock

Liability Limits Premium $____________________ Liability Coverage $_____________ ($100,000 - $300,000 - $500,000 - $1,000,000) $ ___________________ Med Pay Per Person $_____________ (1,000 - $2,000 - $3,000 - $4,000 - $5,000 - $10,000) $ 25,000 Med Pay Per Occurrence

DESCRIPTIONS OF PREMISES Loc # of

Dwell Bldgs. (Y/N)

Acres Sec Twp Rng County State Own/Ten Occ.

Name, Address & Other Info.

Total # of Acres______________ Additional Liability Charges W/MP Quantity Additional Residence Occupied by Insured ________ $_____________ Additional Residence Rented to others ________ $_____________ Additional Premises with buildings ________ $_____________ Additional Insured with a charge (Incl. Trust) ________ $_____________ Home Day Care (not to exceed 6 children) ________ $_____________ Additional Insured_____________________________________ Address_____________________________________________ City__________________________ State______ Zip________ Relationship to Primary Insured________________________ Additional Insured Resides on Premises? YES NO

Additional Insured______________________________________ Address______________________________________________ City__________________________ State______ Zip_________ Relationship to Primary Insured________________________ Additional Insured Resides on Premises? YES NO

Incidental Office Occupancy: ______________ Business____________________________ Receipts: ______________ $_____________ Roadside Stands - Description: ________________________________________________ Receipts: _________________ $_____________ Watercraft – Type of Watercraft: Sailboat Pontoon Speedboat Other______________(NO JETSKIES) Make____________ Model___________ Length________ Top Speed_________ MPH _______HP_______ $_____________ Miscellaneous _______________________________________________________________________________ $_____________ _______________________________________________________________________________________________________________________________________ ** GL 2 Application Only **

$_____________

Farm Employee Status # of Employees Name of Employee Months Exchange Labor Part Time - Full Time

Animal Collision – actual cash value not to exceed $400 each animal Number of animals?_______ $_____________ Custom Farming – Limited to a 50 mile radius: Receipts: ___________________ $_____________ Nature of Custom Farming_________________________________________________________ Increase Farm Pollution ($25,000 Included) $50,000 $100,000 $_____________ □ YES □ NO Do you apply anhydrous ammonia or spray any chemicals? ALL-TERRAIN Vehicles – off premises for owned units - # of ATV’s owned ____ $_____________ Make______________ Model__________________ Serial # _________________ # of cc's __________ I reject ALL-TERRAIN Vehicle coverage. - _____________________________________Date____________ Signature of Applicant (Total Liability Premium) $_____________ Total Premium (Page 1-2-3) $_____________ Service Charge $_____________ Total Annual Premium $_____________ Semi-Annual - Quarterly – Monthly $_____________

FMAPP 01/13 3

FMAPP 01/13 4

UNDERWRITING YES NO 1. __ __ Have you or any member of your household ever been convicted of a felony? If yes, explain_________________________________ 2. __ __ Have you or any member of your household filed for bankruptcy in the last 3 years? If yes, Date and explain in remarks. 3. __ __ Have you or any member of your household been sued on a delinquent account or note? If yes, indicate the following: Date_________________ Amount_________________ Location__________________________________________ 4. __ __ Do you or any member of your household now have or intend to have another policy providing coverage on this property or any part thereof? If yes, explain__________________________________________________ 5. __ __ Have you or any member of your household ever been involved in any litigation, whether covered by this insurance or not? 6. __ __ Is dwelling or buildings for sale or vacant? If yes, explain__________________________________ 7. __ __ Do you have other insurance with the Farm Mutual? Policy #____________________________ 8. __ __ What Insurance Company previously provided Liability insurance for you & Reason for Transfer? ____________________________ 9. __ __ If self employed, describe nature of business _______________________________________________________________________ 10. __ __ Do you conduct any business pursuits on the premises? If yes explain ___________________________________________________ 11. __ __ Is applicant the owner of record? If no, explain_____________________________________________________________________ 12. __ __ Do you occupy the entire principal residence premises? If no explain____________________________________________________ 13. __ __ Number of Unrelated Residents______ Relationship_________________________________________________________________ 14. __ __ Do you rent rooms or apartments to others? If yes # of roomers________ # of apartments________ 15. __ __ Are there any unusual hazards on the premises such as: Child/Daycare Hot Tub 16. __ __ Do you have a trampoline without a safety enclosure and protective padding? 17. __ __ Do you have an unfenced swimming pool? (No slides or diving boards are permitted.) If yes, does it have a self locking gate? _____________ 18. __ __ Do any of the following exist, or are they expected to exist on or off the premises?

__ Hunting for a Fee __ Horse Boarding __Training Horses __Logging __Bed & Breakfast __ Saw Milling __Roadside Stand __ Processing of Farm Products __U-Pick Operations __Auction/Sales/Shows

19. __ __ Are there dogs on the premises? If yes, give breed of all dogs________________________(DON’T USE “MIX” OR “CROSS” ) If you answered Yes to Dogs on premises, answer the following: Trained as guard dogs? ________________________________________ Have a history of biting? ________________________________________ 20. __ __ Is there any indication or history of viciousness of any other animal or pet? If yes explain __________________________________ 21. __ __ Do you own or keep any animals or reptiles commonly considered to be Wild or Dangerous by the general public? 22. __ __ Is any construction in process or contemplated on premises? If yes, explain ______________________________________________ 23. __ __ Have you sustained any property or liability losses. If yes, explain (describe each loss giving Date of Loss, Cause of loss, and extent of any personal injury or property damage.) ______________________________________________________________ 24. __ __ Are there any dwellings without working smoke detectors? _______________________ 25. __ __ Does dwelling have a continuous enclosed masonry foundation?___________________ 26. __ __ Type of Heating Device:__ Permanent Warm Air Furnace __Electric __Ceiling, Wall or floor Furnace __Hot Water __ Steam Boiler __ Other _________________________ 27. __ __ Kind of Fuel: __ Gas __ Oil __ Coal __ Wood __ Other _________________________ 28. __ __ Supplemental Heating: __None __Wood Stove __ Fireplace __ Solar __ Wood Furnace __ Space Heater __ Free Standing Fireplace

__Other ___________________ 29. __ __ Does heating device or supplemental heating have automatic controls? 30. __ __ Type of Chimney? __ Tile Lined __U.L. Approved metal pipe 31. __ __ Do you have any portions of the farm rented, leased, or used for other than farming purposes? If yes, explain____________________ 32. __ __ Do fences for livestock indicate lack of maintenance? If yes, explain____________________________________________________ 33. __ __ Has there ever been an incidence of escape of livestock? If yes, explain REMARKS: ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ APPLICANT’S STATEMENT The undersigned warrants and represents and agrees that statements herein are made with respect to me and all members of my household for the express purpose of inducing the Company to issue an insurance policy and these statements and answers are true, correct, and complete to the best of my knowledge. I understand that any binder of insurance policy issued as a result of this application will be based on the facts and answers stated. I understand that if any premium remittance by or on my behalf is not honored by the payer (bank) it will be deemed nonpayment of premium and no coverage will be afforded. The undersigned authorizes the Company to perform a general investigation including a credit investigation of the applicant(s) for purposes of this insurance coverage. The undersigned authorizes the Company to enter onto the described premises for purpose of inspecting any structure for which this insurance may be applicable. I have read this application before affixing my signature. Applicants Signature ________________________________________________________________ Date ______________________ AGENT’S STATEMENT □ Yes □ No Did you personally inspect the property? □ Yes □ No Does the premises present a neat appearance? □ Yes □ No Is the risk new to your agency? □ Yes □ No Do you know the applicant and applicant’s premises will enough to recommend this as a good risk? If no, explain ___________________ How long have you known the applicant?__________________ How long has applicant lived in the community?________________ Agent’s Signature________________________________________________ Date_____________________ Time_________________