(Check off each Applicable) - Agriculture Insurance

1 Farm Application ChecklistToday's Date___ / ____ / _____Completed by:Applicant Name:Agency Name:Best Telephone #:Email Address:Applications with this information completed will receive preference in Date ___ / ____ / _____Date Quote Needed:___ / ____ / _____Expiring Premium: $Expiring Carrier Name:Target Premium:$Completedby Agent ( check off each applicable ) Coverage Sections, Applications, & Information Completed and Attached o Dwellings Owned, Seasonal, and Non Owned Cov A, B, C, D Older Dwell Questionnaire Over 40 yrso Scheduled Farm Personal Property Cov Eo Unscheduled Farm Personal Property Cov Fo Outbuildings Farm Barns, Buildings, and Structures Cov GInland Marine.

2 O Personal Property Jewelry, Furs, Cameras, Musical Instruments, Silverware, Fine Arts, Golf Equipment, Stamps, Coins, Firearms, Other o Recreational Vehicles Boats, ATVs, Snowmobiles, Golf Carts, OtherDisruption of Farming Operations (Income Loss and Expense Coverage) o Determine the Required Limit & Coinsurance MinimumsFarm Automobile Did you include? o All Drivers including those Employee Drivers Using their Own Vehicles? o List of Auto/Truck (Less than 3 years old) requesting Farm Excesso Diagrams of All Locationso Photos of All Buildings and Structureso Social Security Number of the Named Insured or Primary Partner or Shareholdero Replacement Cost Worksheets o Claims Loss RunPer Occurrence Property DeductionAdditional Interests Did you include?

3 O All Mortgage Interests o All Personal Property Additional Interests o All Liability Additional Interests o If applicable : Equine, Dairy, Poultry, Swine questionnairesDWELLING (ISO COVERAGE A, B, C, & D)Heat Wiring Plumbing RoofingCovA*CovC**DWELLING (ISO COVERAGE A, B, C, & D) Continued Cov ACov C* Valuation Coverage A: RC=Replacement Cost; ERC = Extended Replacement Cost; ACV=Actual Cash Value; FBV=Functional Building Valuation.** Valuation Coverage C: RC=Replacement Cost; ACV=Actual Cost Value^^ Perils: B=Basic BR=Broad S=Special S/BR=Special/Broad** If year built is over 40 years, complete older dwelling supplemental :Page 2 of 8 Unoccupancy or VacancyMORTGAGEE INFORMATIONC ertain causes of loss are excluded with respect to buildings or structures vacant more than 30 consecutive days.

4 Use 'Waiver of Vacancy' to extend coverage beyond 30 #$ Contract for Sale Lender's Loss PayeeUNOCCUPANCY AND VACANCY For Dwellings and ALL OTHER BUILDINGSDwlg # or Bldg #Name and Address/Loan # Loss Payee Contract for Sale Lender's Loss Payee MortgageeA loss condition reduces the applicable Limit of Insurance by 50% if a building or structure is unoccupied or vacant more than 120 consecutive days. Use 'Waiver of Unoccupancy and Vacancy' to waive the Unoccupancy and Vacancy Loss Condition for periods of vacancy and unoccupancy beyond 120 days. Loss PayeeName and Address/Loan #Dwlg # MortgageeStarts:JAIB Appl 0001 0811$$$$$$$$$Loc#Dwlg#Cov D:Loss of UseLimit 20%Cov C:Household PersonalProperty Limit 70%# ofFamiliesDed($1,000 Min)Cov A:DwellingLimit 100%$$$Protective DevicesCov B:Other StructuresLimit 10%Dwlg#YearBuilt**SquareFeetValuationLo c#Roof TypeType of Heat$Dwlg#Dwelling Occupancy(Owner Primary/Owner Seasonal/Tenant)Type of Construction(If mobile home, attach questionnaire)*Attach Cost Estimator for each dwellingSumpOverflow(Y/N)If 40 Years old or more,When was it updated for.

5 $$$DWELLING (ISO COVERAGE A, B, C, & D) Continued Loc#$Perils^^$SupplementalHeat (Attachquestionnaire) (Y/N)Earthquake(Y/N)$ Does Not Apply Waiver of Vacancy Waiver of Unoccupancy and VacancyMineSubsidence(Y/N)Number Loc #Ded. $1,000 MinLimits of InsurancePERILS$$$1$$2$$3$$4$$5$$6$NOT COVERED7$$8$$9$$10$$Loc #Year$$$$$$$$$$$$$$$$$$$$$$$$12 Ded. $500 Minimum$$13 NOT COVERED14# Of Head $$Loc#Item#YearSerial #CC/HP LengthType ofMotorDed.$1, of Insurance $$$$$$$$$$Year12345 JAIB Appl 001 0811 Page 3 of 8 PoultryOther AnimalsRepl. Cost Less Than 5 Years OnlyForeign Objects(Y/N)Cab Glass(Y/N)PerilsFarm machinery, vehicles, equipment on or away from the "insured location" Grain, threshed seeds, beans, ground feed, silage, "livestock" feed, all in buildings, structures, sacks, wagons or TypeFarm machinery, (non auto) vehicles and equipment that you borrow or rent without a written Equipment (not to include Tractors, Combines, Autos, LP or Containers, Tanks, Brooders, Fences, Towers Poles, Irrigation Equipment, Portable Bldgs, or Household Personal Property) Limit per item $2,000 Serial # Mortgagee Loss Payee Lender's Loss PayeePhysDamage(Y/N)

6 Livestock (Cattle, Sheep, Swine, Goats, Horses, Mules, Donkeys) on or away from premise. Valuation the least of (1) Amount of Insurance divided by number of animals times 120%, (2) ACV, or (3) $2,000. [And value for Animals under 1 yr in Age] Perils: Basic or Broad Per Head$Liability(off premises)(Y/N)Name and AddressLimit$$$$$Item # Lender's Loss Payee Loss Payee Contract for Sale Contract for SaleName and AddressADDITIONAL INTERESTS MortgageeDescriptionScheduled Personal Items (Jewelry, Guns, Stamps, Art, ect)Animal CollisionRECREATIONAL VEHICLESC omputers & related software used principally as aids in Farm ManagementTrays, boxes, box shook (unassembled wood crates).

7 Farm products, materials and supplies shown including packing materials & containers, but not hay, grain or any growing , straw or fodder in the open $10,000 Limit per Stack with a 100 separation/clearance between Stacks. Causes of Loss fire or lightning, windstorm or hail, vandalism, vehicles, and , straw, fodder in buildings or in stacks, shocks, swaths or piles in the open, but only with these Causes of Loss fire and lightning, vandalism, vehicles and E SCHEDULED FARM PERSONAL PROPERTYP erils: B=Basic BR=Broad S=SpecialItem Coverage Notes See policy for DetailsEnd DateGRAIN & FEED PEAK SEASON FARM PERSONAL PROPERTY (ISO COVERAGE E)Item #11 Description Make, Model, and Serial #Beginning DateAgriculturalMachinery &Implements# of UnitsUnit PriceTotal ValueAgricultural Produce# of UnitsUnit PriceTotal ValueAgricultural Tools,Equipment & Supplies# of UnitsUnit PriceTotal ValueTillage.

8 BarleyAgri ChemicalsTractorsCornFertilizersFruitHer bicidesGround FeedInsecticidesMfg Stock FeedPesticidesNutsAir CompressorsOatsBinsDiscsSilageBoxes and Box ShookHarrowsSoybeansElectric MotorsPlowsStrawFarm LubricantsOtherWheatFencing & PostsGasoline/Diesel FuelCultivating:Hand ToolsCultipackersMaterials & SuppliesCultivatorsMilking EquipmentDrillsOffice EquipmentPlantersPaintsRotary HoesPicking EquipmentSpeedersLivestock# of unitsUnit PriceTotal ValuePoultry EquipmentSpreadersDairy CowsPower ToolsSprayersDairy HeifersSaddles & TackDairy CalvesSpare PartsHarvesting:Beef CowsTiresAugersBeef CalvesVet SuppliesBlowersFeeder CattleWelders & TorchesChoppersBullsMisc.

9 ToolsCorn PickersSows & GiltsMisc. PartsDriersBoardsElevators (Port.)Feeder PigsForage HarvestersEwesGrain CleanersRamsGrape HarvestersLambsHay BalersHorsesMowersPoniesNut ShakersMulesRakesRice HarvestersSilo FiltersSilo UnloadersTomato HarvestersWagonsDeductibleTotal * Perils: B=Basic BR=Broad S=SpecialJAIB Appl 002 0312 Page 4 of 8$$Limit of insuranceTotal Value$Livestock (Basic and Broad Only)Other Than Livestock$Perils*ItemCoverage F Inventory$1. With Multiguard Endorsement the Irrigation Equipment, Combines, and Cotton Pickers are eligible for coverage under the Coverage F. Unscheduled Farm Personal Property form. 2. The Cause of Loss of Foreign Objects in Farm machine or Mechanical Harvester is only covered when policy contains Multiguard Endorsement with Special Cause of 80% Coinsurance Clause Request Cab Glass Coverage by Adding a List of Units with Description/ID #5.

10 Request Replacement Cost Loss Settlement Coverage for Machinery & Equipment (5 yrs or newer) by Including a List with Unit Description/ID # and Repl Cost FARM PERSONAL PROPERTY (ISO COVERAGE F) ACV VALUATIONAGRIBUSINESS UNSCHEDULED FARM PERSONAL PROPERTY ADDENDUMT otal Value$Total Values$APPLICANT NAMET otal ValueDATE(MM/DD/YYYY)Loc #Bldg#YearBuiltSquareFeetType of ConstRoof TypeRoofAgeType ofHeatProtective DevicesLoc#Bldg #MineSubsidence(Y/N)EQ^^(Y/N)IG%Open Foundation (Y/N)OpenSides(Y/N)Valuation*DedMin $1,000 Perils**Limit of Insurance **Perils: B=Basic BR=Broad S=Special^^EQ=EarthquakeJAIB Appl 002 0412 Page 5 of 8 Limit Requested: $_____Min. Co Insurance Limit Required: $_____Notes:Farm Income Excluded:_____Co Insurance % Requested ( 30%, 40%, 50%, 60% 70%, 80%) _____%Extended Period of Indemnity (30, 60, 90, 120, 180, 360) _____ daysName and Address Lender's Loss Payee Contract for Sale Lender's Loss Payee Loss Payee Contract for Sale Loss PayeeBldg # MortgageeName and AddressBldg # MortgageeFARM BARNS, BUILDINGS AND STRUCTURES (ISO COVERAGE G)DescriptionFarm Receipts.