CDO - PACKAGE HOMEOWNER’S APPLICATION

1 - 1 -CF-346 (Ed. 4-17)Actual Loss sustained in 12 monthsGENERAL AGENT S USE ONLY GA's Initials_____ APPLICATION has been reviewed and - PACKAGE HOMEOWNER S APPLICATION Company 1 - TOWNSHIP MUTUAL Company 2 - STATEWIDE MUTUAL Fire Policy #:_____ APPLICANT: _____ AGENCY: CODE: _____ WIND CO. USEA ddress: _____ _____ Underwriter: _____City/State/Zip: _____ _____ Data Entry: _____Phone: Home:_____ Bus.: _____ _____ Checked By: _____LOCATION OF RISK: Give 911 address for all locations with buildings. Latitude / Longitude: _____Total Acres: _____, , , Range_____, Twp_____,_____County, MN, Rural Fire # _____POLICY TYPE: PRIMARY RESIDENCE SEASONAL RESIDENCE CONDOMINIUMPERILS: Basic Broad Special Preferred ("Classic") NOTE: The perils that apply to the Dwelling also apply to Household Personal Prop.

2 , except when Special Form applies to the Dwelling only Broad Form applies to the Household Personal Prop. unless otherwise : $250 $500 $1,000 Base $1,500 $2,000 $2,500 $5,000 $10,000 COVERAGE AND LIMITS: NOTE: Applicant may determine amount of coverage applying to Coverage B and Coverage C . LIMITS: Year A Residence B Related C Household D Increase In L Personal Liability M Med Pay Built Structures Personal Property Living Cost (Each Occurrence) (Each Person) BILLING MODE: Annual Semi-Annual Quarterly Other_____ BILL PREMIUM TO: Insured Agency Escrow/Direct Bill ONLY PREMIUM SECTION Co. One Co. Two CombinedBasic Charges: .. DISCOUNTS Yes No Auto Companion Discount Policy # _____ _____ Yes No New/Upgraded Home Component Discount .. _____ Yes No Metal Roof Discount (Cosmetic Damage Exclusion applies).

3 _____ Yes No Other: List: _____ _____OPTIONAL COVERAGES: Property Yes No Replacement Cost - Household Personal Property .. _____ Yes No Special Form - Household Personal Property .. _____ Yes No Added Perils Refrigerated Foods Total Amount: $_____ .. _____ Yes No Water or Sewer Backup Total Amount: $_____ .. _____ Yes No Modified Replacement Cost _____% (50%, 60%, 70%, 80%).. _____ Yes No Other Structures PH 48: _____ _____ Yes No Underground Service Line Coverage .. _____ Yes No Fire Department Service Total Amount: $_____ .. _____ Yes No Identity Fraud Expense Total Amount: $_____ .. _____ Yes No Other: List: _____ _____OPTIONAL COVERAGES: Liability Yes No Additional Insured - Named _____ Yes No Additional Residence Maintained .. _____ Yes No Additional Residential Premises Rented To Others.

4 _____ No. of Families:_____ Location: _____ Yes No Business Activities: Type: _____ _____ Yes No Care Provided For Others: .. _____ Yes No Farm Liability (See page 2 - information must be completed) .. _____ Yes No Office, Professional, Private School or Studio Use Type:_____ Receipts: _____ Yes No Personal Injury (Included on "Classic") .. _____ Yes No Recreational Motor Vehicle Liability .. _____ Yes No Watercraft Liability .. _____ Yes No Other: List: _____ _____OPTIONAL COVERAGES: Inland Marine (complete page 3) Yes No .. TOTAL PREMIUM $ $ $Requested Effective Date:_____12:01 standard time at location described New Renewal of:_____- 2 -PROPERTY UNDERWRITINGD rivers License: Appl.

5 : _____ Spouse: _____ Other policies with either carrier? Yes NoSocial Security #: Appl.: _____ Spouse: _____ List other policies: Policy #:_____Occupation: Appl.: _____ Spouse: _____ Policy #: _____FIRE PROTECTION: PROTECTED PARTIALLY PROTECTED UNPROTECTED_____ Miles from responding Fire Department _____ Feet from Fire HydrantProtective Devices - Premium Credits:_____ Central Alarm System Residential Sprinkler Smoke Detector Other: List_____ Number of Families:_____PREVIOUS CARRIER: _____Has the policy been refused or cancelled in the past 5 years? Yes No If Yes, Explain: _____LOSS EXPERIENCE: Check here if no all losses in the past 5 years and any losses ever over $10,000. (Dates, Type & Amount) _____INSPECTION: When was the risk last inspected by the agent? _____DWELLING UNDERWRITINGDWELLING REPLACEMENT COST ESTIMATE - Use the MS/B RCT software program and ATTACH THE RCT PRINTOUT.

6 Overall Condition of the Dwelling: Excellent Good Average Below Average1. Heating: Age:_____ Type:_____ Condition:_____ Central: Yes No 2. Wiring: Age:_____ Type:_____ Condition:_____ Amps:_____ Rewired: Completely Partially 3. Plumbing: Age:_____ Type:_____ Condition:_____ 4. Siding: Age:_____ Type:_____ Condition: _____5. Roof: Age:_____ Condition: _____ Type: Asphalt Shingles Wood Shakes or Shingles Metal Other: _____ 6. Is this a pre-manufactured home? Yes No 7. Solor Heating: Yes No If Yes, explain on separate memo. 8. Is there any type of solid fuel heating equipment? Yes No If Yes, fill out Page 4 OTHER STRUCTURES UNDERWRITINGAll Structures, insured or not, must be listed. Include Dimensions and Star CDO may be written if there are no more than 2 appurtenant structures (insured or not) on premises.

7 One is covered under Coverage B, second must be listed on PH48. Buildings over 1600 sq. ft. need prior underwriting Building Type: _____ Dimensions:_____x_____ Coverage B PH 48 a. Heating: Age:_____ Type:_____ Condition:_____ Central: Yes No d. Plumbing: Age:_____ Type:_____ Condition: _____ b. Wiring: Age:_____ Type:_____ Condition:_____ Amps:_____ e. Siding: Age:_____ Type:_____ Condition: _____ c. Roof: Age:_____ Type:_____ Condition:_____ Metal Roof Discount (PH 48) (Cosmetic Damage Exclusion applies) 2. Building Type: _____ Dimensions:_____x_____ Coverage B PH 48 a. Heating: Age:_____ Type:_____ Condition:_____ Central: Yes No d. Plumbing: Age:_____ Type:_____ Condition: _____ b. Wiring: Age:_____ Type:_____ Condition:_____ Amps:_____ e. Siding: Age:_____ Type:_____ Condition: _____ c.

8 Roof: Age:_____ Type:_____ Condition:_____ Metal Roof Discount (PH 48) (Cosmetic Damage Exclusion applies)SPECIAL RESTRICTIONS: PH900 or PH901 Actual Cash Value Shingles CF-1742 Actual Cash Value Exterior SurfacesOther: _____LIABILITY UNDERWRITINGIs there a Trampoline? Yes No Is there a Swimming Pool on premises? Yes No Type_____ Diving Board or Slide? Yes No Is there a fence around the pool? Yes NoDoes applicant own Dog(s)? Yes No #:_____ What Breed(s)?_____Has Dog(s) ever bitten anyone? Yes NoIs there Day Care Exposure? Yes No If Yes, how many children?_____Policy #_____Do all Steps and Deck Structures have adequate railings? Yes NoHorses? Yes No #_____ Parades/Shows? Yes No Any Horses boarded? Yes No If Yes, explain: _____Other Livestock?

9 Yes No #_____ Type: _____Number of Acres? _____ (over 40 need FPL) Condition of Fences? Good Fair PoorAny Custom Farming? Yes No If Yes, explain: _____ Non-Farming Discount (No farm land operated by the insured/no making of hay and with 5 or less head of horses/other livestock.)Applicant'sInitialsApplicant' sInitials- 3 -OPTIONAL INLAND MARINE COVERAGES AND UNDERWRITINGSCHEDULED PROPERTYSCHEDULE OF ARTICLES TO BE INSURED. (Note: Be sure to give complete descriptions, cost, serial numbers, if any, name of manufacturers, year, etc.) Attach Bill of Sale or Appraisal Slip on articles with values of $3,000 or more. For computers, please indicate which items are equipment (and value) and which items are software (and value). Amount of Date Ins.

10 - 100% Description or Make Serial Number Purchased Cost Ded. Rate to Value FOR WATERCRAFT AND RECREATIONAL MOTOR VEHICLES ONLY Is the watercraft equipment used for water skiing or racing?_____ Explain: _____Are the recreational vehicles ever entered in any racing events?_____ Explain: _____Was any driver license suspended or revoked in the last 3 years?_____ Explain: _____ Date of Name of All Operators Relationship Birth Drivers License Number % UseCOMMENTS:LOSS PAYABLE: 1. _____ 2. _____ _____ _____ _____ _____ Property: _____ Property: _____WATERCRAFT (Boats, Motors, Trailers, Docks, Boat Lifts, Personal Watercraft (Wet Bikes, Jet Skis, etc.), Fish Locators and Paddle Boats) Amount of Serial Non- Ins.