CPP FORMS - MN - North Star Mutual Insurance Company

1 CPP FORMS - MN. form NUMBERS &. EDITION DATES COMP. TITLE. COMPUTER GENERATED CPP DECLARATIONS. L 1-13 NSM TOTAL LOSS ENDORSEMENT (APPLIES TO WINDSTORM or HAIL PERIL). SPC 1-13 MAFMIC SPECIAL PACKAGE OF COVERAGES (Policies with North Star Mutual will not use SPC but will instead use NS-781B.). V 1-13 MAFMIC RESTRICTION OF INDIVIDUAL POLICIES. W 1-13 MAFMIC DEFERRED LOSS PAYMENT. X 1-13 MAFMIC DEFERRED LOSS PAYMENT. Y 1-13 MAFMIC MODIFIED REPLACEMENT COST PROVISION EXPANDED COVERAGE. DWELLING (Coverage A). TP1 1-13 MAFMIC STANDARD POLICY TABLE OF CONTENTS, AGREEMENT, POLICY. PERIOD, GENERAL POLICY PROVISONS, DEFINITIONS, PRINCIPAL. PROPERTY COVERAGES AND EXCLUSIONS, INCIDENTAL PROPERTY. COVERAGES, PERILS WE INSURE AGAINST AND EXCLUSIONS, GENERAL. EXCLUSIONS, PROPERTY NOT COVERED, HOW MUCH WE PAY FOR LOSS. OR CLAIM, DUTIES AFTER LOSS, PAYMENT OF LOSS OR CLAIM, POLICY. CONDITIONS, AND OPTIONAL COVERAGES.

2 The following Optional Coverages are in the TP1: J MAFMIC REPLACEMENT COST COVERAGE (Coverage A or G). K MAFMIC REPLACEMENT COST ENDORSEMENT (Coverage C). P MAFMIC COLLAPSE DUE TO WEIGHT OF ICE, SNOW OR SLEET (Coverage G). Provided by the Statewide Mutual Company . Q MAFMIC ADDED PERILS FOR REFRIGERATED FOOD PRODUCTS (Coverage C). Provided by the Township Mutual . R MAFMIC CAB GLASS (Coverage E or F). S MAFMIC PEAK SEASON INVENTORY FARM PERSONAL PROPERTY (Coverage E or F). T MAFMIC FARM EXTRA EXPENSE (Coverage E, F, or G). U MAFMIC RECREATIONAL EQUIPMENT. 7U MAFMIC BACKUP OF SEWERS, DRAINS OR SUMP SYSTEMS (THIS IS NOT FLOOD. Insurance ) (Coverages A and C) Provided by the Township Mutual . 6J MAFMIC MODIFIED REPLACEMENT COST (Coverage A). 7B MAFMIC NON-DEPRECIATION OF REPAIRS (Coverage E or F). Z MAFMIC COVERAGE ADJUSTMENT. 6S MAFMIC DEBRIS REMOVAL (Coverage A, C, E, F, or G). 7W MAFMIC EXPANDED COLLISION AND/OR OVERTURN PLUS (Coverages E and F).

3 Provided by the Township Mutual . 7Y MAFMIC EXPANDED COLLISION AND/OR OVERTURN (Coverages E and F) Provided by the Township Mutual . AM MAFMIC AMENDED FAILURE TO MATCH (Coverage A). 7S MAFMIC AMENDED THEFT - Expanded Coverage Provided by the Township Mutual . 6K MAFMIC BLIZZARD DEATH COVERAGE LIVESTOCK (Coverage E or F) Provided by the Statewide Mutual Company . 6P MAFMIC LIVESTOCK CONFINEMENT COVERAGE (Coverage E or F) Provided by the Statewide Mutual Company . 6R MAFMIC SCHEDULED CAB GLASS (Coverage E or F). 7X MAFMIC EXPANDED VEHICLE DAMAGE Provided by the Township Mutual . 6C2 4-16 MAFMIC HOUSEHOLD PERSONAL PROPERTY EXTRA. 6C3 4-16 MAFMIC HOUSEHOLD PERSONAL PROPERTY PREMIER. 6L 4-15 MAFMIC AMENDATORY ENDORSEMENT. 6M 4-15 MAFMIC EXCLUSION OF LOSS DUE TO BY-PRODUCTS FROM PRODUCTION OR. PROCESSING PRODUCTS. Page 1 of 3. CPP FORMS - MN. form NUMBERS &. EDITION DATES COMP. TITLE. PDN-6M 4-15 MAFMIC POLICYHOLDER DISCLOSURE NOTICE (Exclusion of Loss due to By-Products from Production or Processing Products).

4 6Q 1-13 MAFMIC SPECIAL EXTENSION OF COVERAGE FOR LIVESTOCK (Coverage E or F). Provided by the Township Mutual . 6UC 4-16 MAFMIC BUILDING UNDER CONSTRUCTION. 6W 1-13 MAFMIC DEFERRED LOSS PAYMENT. 6X 1-13 MAFMIC DEFERRED LOSS PAYMENT. 7A 1-13 MAFMIC COLLAPSE WEIGHT OF ICE, SNOW OR SLEET (Coverage E or F) Provided by the Township Mutual . 7AI 1-13 MAFMIC ADDITIONAL INSUREDS. 7BI 04-18 MAFMIC NON-DEPRECIATION OF REPAIRS TO IRRIGATION EQUIPMENT. 7C 1-13 MAMFIC AMENDED VANDALISM OR MALICIOUS MISCHIEF AND THEFT EXPANDED. COVERAGE Provided by the Township Mutual . 7D 1-13 MAFMIC AMENDED VANDALISM OR MALICIOUS MISCHIEF EXPANDED COVERAGE. Provided by the Township Mutual . 7H 1-13 MAFMIC EARTHQUAKE Provided by the Township Mutual . 7J 1-13 MAFMIC THEFT COVERAGE EXTENSION CONSTRUCTION MATERIALS AND. SUPPLIES (Coverage A or G) Provided by the Township Mutual . 7LF 4-15 MAFMIC LIMITED FUNGUS, BACTERIA, WET ROT, OR DRY ROT COVERAGE.

5 PDN-7LF 4-15 MAFMIC POLICYHOLDER DISCLOSURE NOTICE (Limited Fungus, Bacteria, Wet Rot, or Dry Rot Coverage). 7N 1-13 MAFMIC LOSS OF INCOME ENDORSEMENT (Coverage G) (Applies to livestock farming operation). 7P 1-13 MAFMIC LEASED, RENTED OR BORROWED FARM MACHINERY, VEHICLES and EQUIPMENT (Coverage E). 7Q 1-13 MAFMIC COLLAPSE WEIGHT OF ICE, SNOW OR SLEET COVERAGE (Coverage G). Provided by the Township Mutual . 7R 1-13 MAFMIC LOSS OF USE OR INCOME ENDORSEMENT (Coverage G). PDN-8FL 8-08 MAFMIC FLOOD DISCLOSURE OF NO COVERAGE. 8TL 01-15 MAFMIC CERTIFIED TERRORISM LOSS COVERAGE/NON-CERTIFIED TERRORISM. LOSS EXCLUSION/NUCLEAR, BIOLOGICAL, CHEMICAL AND. RADIOLOGICAL EXCLUSION/WAR AND MILITARY ACTION EXCLUSION. PDN-8TL 01-15 MAFMIC NOTICE TO POLICYHOLDERS NOTICE OF TERRORISM Insurance . TP AEHT 4-16 MAFMIC AMENDATORY ENDORSEMENT OUTDOOR HOT TUBS, WHIRLPOOLS &. SPAS ACTUAL CASH VALUE. PDN TP1 AEHT4-16 MAFMIC POLICY DISCLOSURE NOTICE (Do not show form number or edition date on Declarations.)

6 Use to notify current policyholder of changes that have been made that will affect their coverage regarding outdoor hot tub & whirlpool coverage. To be sent to all policyholders of those mutuals who opt to adopt the TP AEHT Endorsement). TP1 AEPJI 04-18 MAFMIC AMENDATORY ENDORSEMENT PREJUDGMENT INTEREST. PDN TP1 AEPJI 04-18 MAFMIC POLICY DISCLOSURE NOTICE (Do not show form number or edition date on Declarations. Use to notify current policyholder of changes that have been made that will affect their coverage regarding prejudgment interest). CIE 04-18 MAFMIC COLLISION OF IRRIGATION EQUIPMENT. TP10 03-03 MAFMIC NOTICE OF CANCELLATION OR NON-RENEWAL. TP-10R 12-03 MAFMIC NOTICE OF CANCELLATION OR NON-RENEWAL (RAM Mutual uses this). TP12 03-03 MAFMIC NOTICE OF CANCELLATION NON-PAYMENT. TP12R 12-03 MAFMIC NOTICE OF CANCELLATION NON-PAYMENY (RAM Mutual uses this). NS-25 09-09 NSM CONSENT TO MOVE MOBILE HOME.

7 NS-26 09-09 NSM COLLISION OR OVERTURN OF MOBILE HOME. NS-27A 1-13 NSM SECURED PARTY'S INTEREST COVERAGE (Basic). NS-28A 1-13 NSM SECURED PARTY'S INTEREST COVERAGE (Comprehensive). Page 2 of 3. CPP FORMS - MN. form NUMBERS &. EDITION DATES COMP. TITLE. NS-0420 7-15 NSM INSTALLED EQUIPMENT BREAKDOWN COVERAGE. CF-580 11-13 NSM PREFERRED DWELLING SUPPLEMENTAL APPLICATION. CF-592 8-10 NSM LIVESTOCK CONFINEMENT COVERAGE SUPPLEMENT APPLICATION. NS-781B 1-13 NSM SPECIAL PACKAGE OF COVERAGES (1 unit). NS-781C 1-13 NSM SPECIAL PACKAGE OF COVERAGES (2 units). NS-994 4-15 NSM MINNESOTA AMENDATORY ENDORSEMENT. CF-1000 4-19 NSM COMBINATION PACKAGE APPLICATION. CF-1000a 4-13 NSM PREMIUM COMPUTATION AND WORKSHEET/CLASS G SCHEDULE. CF-1008 4-13 NSM FARM PERSONAL PROPERTY INVENTORY. CF-1098 1-13 NSM LOSS OF INCOME (POULTRY BUILDINGS). NSCF-1243 8-11 NSM NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY.

8 UNDER THE MINNESOTA Insurance GUARANTY ASSOCIATION LAW (MN). (We rely on the Agents to give a copy of this notice to the applicant when an application is taken. The notice must be given in writing or in the same medium as the application for Insurance . This notice would only be attached to renewal certificates if the renewal increases the dollar amount of a coverage by more than 100%) (The NSCF-1243 will not show on the dec!). CF-1297 1-13 NSM DELUX DWELLING PLUS ENDORSEMENT. CF-1358 4-18 NSM SPECIAL form - DEDUCTIBLE AND ADDITIONAL PROVISION APPLICABLE. TO FARM PERSONAL PROPERTY Applies to North Star Mutual . CF-1379 6-94 NSM NOTICE TO POLICYHOLDERS ADDITION OF PERSONAL INJURY. COVERAGE. CF-1545 9-09 NSM ACTUAL CASH VALUE LOSS SETTLEMENT WINDSTORM OR HAIL LOSSES. TO ROOFS Applies to the North Star Mutual . CF-1694 10-02 NSM THE North STAR Mutual COMMITMENT TO PRIVACY (Send with new policies and renewals.)

9 This has to be sent annually.) (CF-1694 will not show on the Dec!). CF-1758 1-13 NSM POLICYHOLDER DISCLOSURE NOTICE PLEASE READ (Do not show form number or edition date on Declarations. Send with policy whenever the CF-1545 [ACV Loss Settlement Windstorm or Hail Losses to Roof] is attached to a CPP policy for the first time.). Applies to the North Star Mutual . CF-1859 2-17 NSM IDENTITY THEFT INFORMATION. CF-1908 3-17 NSM CPP POLICY JACKET. CF-2018 1-13 NSM COSMETIC DAMAGE EXCLUSION (cosmetic damage caused by hail) (applies to Farm Barns, Buildings, Structures & Outbuildings) Applies to North Star Mutual CF-2058 4-13 NSM COSMETIC DAMAGE EXCLUSION (applies to Dwellings) Applies to North Star Mutual CF-2160 4-17 NSM UNDERGROUND SERVICE LINE COVERAGE. CF-2162 4-17 NSM COMMON LOSS DEDUCTIBLE. NS-2786 8-06 NSM IDENTITY FRAUD EXPENSES Provided by North Star Mutual FARM/PERSONAL LIABILITY FORMS . For liability FORMS that can be added to the CPP policy, see the Farm Personal Liability/Personal Liability FORMS listing ( form LISTS\ form LISTS - \PLFI.

10 LE). INLAND MARINE FORMS . For Inland Marine FORMS that can be added to the CPP policy, see the Inland Marine FORMS Listing. ( form . LISTS\ form LISTS - \IMFIL. E). Page 3 of 3.