COMMERCIAL UMBRELLA APPLICATION

1 COMMERCIAL UMBRELLA APPLICATION . Quotation New Business Box 48 Cottonwood, Minnesota 56229. EFFECTIVE DATE: _____ POLICY TERM: 1 YEAR. APPLICANT AND MAIL ADDRESS AGENCY AND MAIL ADDRESS AGT. Phone No.: Phone No.: Fax No.: UMBRELLA LIMIT (Non-binding): $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000. DIRECT BILL INSTRUCTIONS: Insured Other_____ SELF-INSURED RETENTION: $10,000. New Business - 1 months premium required with APPLICATION . THE NAMED INSURED IS: Individual Corporation Partnership Other_____. A. LOCATION OF PREMISES: Location (Include 911 Address) County No. 1. No. 2. No. 3. B. DESCRIPTION OF OPERATIONS: Location On Premises Off Premises No.

2 1. No. 2. No. 3. C. ANNUAL PAYROLL:_____ D. ANNUAL SALES:_____. E. NUMBER OF EMPLOYEES?_____ F. DO EMPLOYEES USE THEIR PERSONAL VEHICLES FOR BUSINESS? Yes No G. AUTOMOBILES: Owned, leased or furnished for regular use CHECK ONE CHECK ONE. RADIUS OF OPERATION. YEAR, MAKE AND MODEL TYPE OF VEHICLE OR GROSS VEHICLE WEIGHT (Regular & Frequent Use). Private Passenger 10,001-20,000 pounds 1-50 Miles 10,000 pounds or less 20,001 and over 51-200 Miles Over 200 Miles Private Passenger 10,001-20,000 pounds 1-50 Miles 10,000 pounds or less 20,001 and over 51-200 Miles Over 200 Miles Private Passenger 10,001-20,000 pounds 1-50 Miles 10,000 pounds or less 20,001 and over 51-200 Miles Over 200 Miles Private Passenger 10,001-20,000 pounds 1-50 Miles 10,000 pounds or less 20,001 and over 51-200 Miles Over 200 Miles NOTE: For additional vehicles, attach a separate memo with above information for each vehicle.

3 Any hauling for hire? Yes No If Yes, give details_____. H. ALL LICENSED DRIVERS OPERATING BUSINESS VEHICLES: Name Drivers License Number Date of Birth No. 1. No. 2. No. 3. I. WATERCRAFT/REC. VEHICLE: Describe owned or chartered watercraft/rec. vehicle and its _____ Does the underlying policy cover this exposure? Yes No J. ADVERTISING LIABILITY: Describe all radio, television and publishing activities of the applicant planned for the next twelve _____. Describe any other advertising activity planned for the next twelve months. ( , contests, exhibits, air shows, rodeos)_____. _____. CF-425 (Ed. 2-18) REVERSE SIDE MUST BE COMPLETED. K. PRODUCTS: List products manufactured, sold, handled or _____ Annual Sales $_____.

4 L. COMPLETED OPERATIONS: Does applicant have a completed operations exposure? Yes No If Yes, explain_____. _____ Annual Revenue $_____. M. CONTRACTUAL LIABILITY: Describe any contractual liability assumed by applicant other than liability assumed under any leases of premises, easement agreement, agree- ment required by municipal ordinance, sidetract agreement, elevator or escalator maintenance _____. N. INDEPENDENT CONTRACTORS: Are Independent Contractors hired? Yes No If Yes, explain_____. _____. O. AIRCRAFT: Does applicant own, hire or use any aircraft? Yes No If Yes, explain_____. PRIMARY UNDERLYING INSURANCE: Minimum Required Limits COMMERCIAL General Liability Premises/Operations: $500,000 Each Occurrence and $1,000,000 General Aggregate Products/Completed Operations: $1,000,000 General Aggregate COMMERCIAL Automobile Liability, Including Non-Owned and Hired Car coverage $500,000/$500,000 Bodily Injury and $100,000 Property Damage or $500 Combined Single Limit Employers Liability: $100,000 Each Accident, $100,000 Each Employee Disease and $500,000 Policy Limit Disease UNDERLYING INSURANCE: List all liability and compensation policies to apply as underlying insurance.

5 TYPE OF POLICY INSURANCE POLICY LIMITS INSURANCE NUMBER COMPANY Effective Date Each Occur. Products General Aggregate COMM. GENERAL. LIABILITY. POLICY INSURANCE POLICY LIMITS NUMBER COMPANY Effective Date CSL. COMM. AUTO. LIABILITY. WORKERS COMP. (EMPLOYERS LIA). Does the Primary Insurance cover the hazards listed below? (Indicating yes does not imply that the UMBRELLA provides coverage). a. Products - Completed Operations Yes No f. Garagekeepers Legal Liability Yes No b. Blanket Contractual Yes No g. Fire Legal Liability Yes No c. Personal Injury Yes No h. COMMERCIAL Auto Liability Yes No d. Liquor Liability Yes No i. Non-Owned Auto Yes No e.

6 X, c, u Exposures Yes No j. Non-Owned Watercraft Yes No Describe any extensions or limitations of coverage in the primary policies:_____. _____. LOSS EXPERIENCE: List all losses paid or now reserved in amounts greater than $10,000 during past five years. (Show total amounts for each loss, not just amounts over $10,000.). AMOUNTS OF LOSSES. DATE OF PAID OUTSTANDING. ACCIDENT DESCRIPTION OF ACCIDENT COVERAGE IS NOT BOUND. NOTICE - READ BEFORE SIGNING - As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting department of North Star Mutual to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit (or credit-based insurance score), character, and/or condition of the property represented on this APPLICATION .

7 I understand that I have the right to make a request in writing as to the nature of any such information that may be developed and that I have the right to request that any such information be corrected by providing documented support for such correction. If my request is denied, I understand that I have the right to appeal to the Commissioner/Director (Minnesota Commissioner of Commerce, 85 7th Place East, Suite 500, St. Paul, MN 55101-2198; Nebraska Director of Insurance, Terminal Building, 941 "O" Street, Suite 220, Lincoln, NE 68508-2089; North Dakota Commissioner of Insurance, 600 East Boulevard Avenue-5th Floor, Bismarck, ND 58505-0320; South Dakota Director of Insurance, 445 East Capitol Ave, Pierre, SD 57501-3185; Iowa Insurance Commissioner, Two Ruan Center, 601 Locust St.)

8 4th Floor, Des Moines, IA 50309-3738; Wisconsin Commissioner of Insur- ance, PO Box 7873, Madison, WI 53707-7873). I understand that in MN only, this is a temporary authorization that will expire as soon as one of the following occurs: (a) The above named company makes the underwriting decision(s) in question, or (b) one year elapses after the date I sign this authorization. However, if a policy is issued, then I authorize the above permission for subsequent amendments and renewals as long as the policy remains in-force. If this APPLICATION for insurance is accepted, I grant permission to North Star Mutual to disclose information to the Mortgagee(s) or Loss Payee(s) that may be designated in this APPLICATION or its(their) successor(s).

9 (Reports prepared by insurance-support organizations may be retained by them and disclosed to others.) INSURANCE FRAUD IS A CRIME - I understand that a person who submits an APPLICATION or claim information with intent to defraud an insurer is guilty of a crime. Applicant's Signature_____ Date_____. As the Agent for the applicant, I attest that the information in this APPLICATION and attachments is correct to the best of my knowledge. Agent's Signature_____ Date_____.