CDO - PACKAGE HOMEOWNER’S APPLICATION

1 CDO - PACKAGE HOMEOWNER'S APPLICATION . Company 1 - TOWNSHIP MUTUAL Requested Effective Date: Company 2 - STATEWIDE MUTUAL. _____. 12:01 standard time at location described New Fire Policy #:_____ Renewal of:_____. APPLICANT:_____ AGENCY: CODE:_____ WIND CO. USE. Address:_____ _____ 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 CONDOMINIUM. PERILS: Basic Broad Special Preferred ("Classic") NOTE: The perils that apply to the Dwelling also apply to Household Personal Prop., except when Special Form applies to the Dwelling only Broad Form applies to the Household Personal Prop.

2 Unless otherwise requested. DEDUCTIBLE: $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). Actual Loss sustained in 12 months BILLING MODE: Annual Semi-Annual Quarterly Other_____ GENERAL AGENT'S USE ONLY GA's Initials_____. BILL PREMIUM TO: Insured Agency Escrow/Direct Bill ONLY APPLICATION has been reviewed and approved. PREMIUM SECTION Co. One Co. Two Combined Basic Charges:.. DISCOUNTS. Yes No Auto Companion Discount Policy #_____ _____. Yes No New/Upgraded Home Component _____. Yes No Metal Roof Discount (Cosmetic Damage Exclusion applies).

3 _____. Yes No Other: List:_____ _____. OPTIONAL COVERAGES: Property Yes No Replacement Cost - Household Personal _____. Yes No Special Form - Household Personal _____. 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:_____ _____. q Yes q No Underground Service Line _____. 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 _____. Yes No Additional Residential Premises Rented To _____. No. of Families:_____ Location:_____. Yes No Business Activities: Type:_____ _____. Yes No Care Provided For Others.

4 _____. 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 _____. Yes No Other: List: _____ _____. OPTIONAL COVERAGES: Inland Marine (complete page 3). Yes No .. TOTAL PREMIUM $ $ $. CF-346 (Ed. 4-17) -1- PROPERTY UNDERWRITING. Drivers License: Appl.:_____ Spouse:_____ Other policies with either carrier? Yes No Social 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 Hydrant Protective Devices - Premium Credits:_____.

5 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 losses. Applicant's Initials List 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 UNDERWRITING. DWELLING REPLACEMENT COST ESTIMATE - Use the MS/B RCT software program and ATTACH THE RCT PRINTOUT. Overall Condition of the Dwelling: Excellent Good Average Below Average 1. Heating: Age:_____ Type:_____ Condition:_____ Central: Yes No 2. Wiring: Age:_____ Type:_____ Condition:_____ Amps:_____ Rewired: Completely Partially 3. Plumbing: Age:_____ Type:_____ Condition:_____ 4.

6 Siding: Age:_____ Type:_____ Condition:_____. 5. Roof: Age:_____ Condition:_____. Asphalt Shingles Wood Shakes or Shingles Metal Type: 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 UNDERWRITING. All Structures, insured or not, must be listed. Include Dimensions and Photos. North Star CDO may be written if there are no more than 2 appurtenant structures (insured or not) on premises. One is covered under Coverage B, second must be listed on PH48. Buildings over 1600 sq. ft. need prior underwriting approval. 1. Building Type: _____ Dimensions:_____x_____ Coverage B PH 48 a. Heating: Age:_____ Type:_____ Condition:_____ Central: Yes No d. Plumbing: Age:_____ Type:_____ Condition:_____.

7 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. Roof: Age:_____ Type:_____ Condition:_____ Metal Roof Discount (PH 48) (Cosmetic Damage Exclusion applies). Applicant's SPECIAL RESTRICTIONS: PH900 or PH901 Actual Cash Value Shingles CF-1742 Actual Cash Value Exterior Surfaces Initials Other:_____. _____. LIABILITY UNDERWRITING. Is there a Trampoline? Yes No Is there a Swimming Pool on premises?

8 Yes No Type_____ Diving Board or Slide? Yes No Is there a fence around the pool? Yes No Does applicant own Dog(s)? Yes No #:_____ What Breed(s)?_____Has Dog(s) ever bitten anyone? Yes No Is there Day Care Exposure? Yes No If Yes, how many children?_____Policy #_____. Do all Steps and Deck Structures have adequate railings? Yes No Horses? Yes No #_____ Parades/Shows? Yes No Any Horses boarded? Yes No If Yes, explain:_____. Other Livestock? Yes No #_____ Type:_____. Number of Acres? _____ (over 40 need FPL) Condition of Fences? Good Fair Poor Any 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.). -2- OPTIONAL INLAND MARINE COVERAGES AND UNDERWRITING. SCHEDULED PROPERTY. SCHEDULE OF ARTICLES TO BE INSURED.

9 (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. - 100%. Description or Make Serial Number Purchased Cost Ded. Rate to Value Prem. COMPLETE 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 % Use COMMENTS: LOSS PAYABLE: _____.

10 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. - 100%. Year Manufacturer / Model HP Lgth Speed Number Dep. Ded. Rate to Value Prem. BOAT Outboard I/O. BOAT Outboard I/O. PERSONAL WATERCRAFT XX XX. MOTOR #1 XX MOTOR #2 XX. TRAILER XX XX XX. BOAT LIFTS DOCKS XX XX XX. FISH LOCATORS XX XX XX. OTHER_____. ACCESSORIES - include anchors, cushions, lights, oars, horns, fuel containers, life preservers and other items used for the safety and operation of the boat. (Skiing and Fishing equipment must be scheduled and rated as Sports Equipment.). RECREATIONAL VEHICLES COVERAGE - SNOWMOBILES, ATV'S, GOLF CARTS AND TRAILERS. Amount of Type of Year Manufacturer Serial Max Pur.