farm partner application ram mutual insurance …fire policy number: ram mutual insurance company...
TRANSCRIPT
Fire Policy Number:
RAM Mutual Insurance CompanyP.O. Box 308
Esko, MN 55733
TM41 3-09
AND
Farm Partner Application
Individual Partnership Corporation Other New Renewal of Policy #:
Name: From: To:
Address: (12:01 am at address of named insured)
General Agency: Annual Semi-Annual Quarterly
Phone #: Insured: Annual Monthly* RAM-Pay*
Social Security #: *Requires minimum initial payment of 2 months)
Perils/Policy Included: Fire Windstorm and Hail FCPL CPL
Inland Marine* (Complete Supplemental Application) OL&T (Complete Separate Application)
Deductible: $250 $500 Included $1,000 $2,500 $5,000 $10,000 $25,000
Mortgagee Loss Payee C/D Mortgagee Loss Payee C/D
Description of Premises: List all property owned, leased, rented, or maintained.
Farm No. No. of
Dwellings Sets of
Buildings Acres Quarter Section
Sec-tion Twp. Range Township Fire # County State
Interest Owner or Tenant
1
2
3
4
UNDERWRITING GUIDE - Furnish photos of all buildings All questions must be answered or application may be returned. If asked to explain or list, please use the space provided, if more room is needed please list the question number, explanation, and attach a separate memo.
1. Date of last on-site inspection and by whom:
2. Principal farm operations are: Grain Dairy Livestock Poultry Occupation other than farming:
3. General housekeeping and condition of premises: Excellent Good Fair Poor
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4. Dwelling:
A. Age of dwelling: G. Wood heating system: Yes No
B. Age of roof: Type: Central Space Fireplace
C. Age of wiring: # of Amps: Age in years:
D. Age of plumbing: H. Smoke Alarm(s): Yes No
E. Occupancy: I. Fire Extinguisher(s): Yes No
Owner Tenant Unoccupied J. Solar heating: Yes No If Yes, explain:
Vacant Seasonal Under Construction Other:
F. Central Heating: Yes :tnempiuqe gnitareneg dniW .K oN Yes No
Type:
Age of heating unit in years:
5. Outbuildings: If an answer to a question is Yes, list the building and please explain.
A. Occupied by: Owner Tenant Off-premises Tenant
B. Condition of buildings: Excellent Good Fair Poor
C. Any building not used for designed purpose? Yes No
D. Do any outbuildings have:
Heating? Yes No Exposed Insulation? Yes No Existing damage? Yes No
E. Condition of wiring in buildings: Excellent Good Fair Poor
F. Are buildings unused or vacant? Yes No
G. Are there any buildings where wind coverage should be: Restricted? Yes No Omitted? Yes No
6. Liability Survey:
A. Does the applicant have: D. Does the applicant own any livestock? Yes No
Seasonal property? Yes No E. Does the insured own horses? Yes No #:
Rental property? Yes No Away from premises? Yes No
Swimming pool? Yes No Does insured board other horses? Yes No #:
Trampoline? Yes No F. Does applicant own dog(s)? Yes No #:
Roadside stand? Yes No Breed(s):
Business office or incidental sales? Yes No
B. Does applicant do custom farming? Yes No G. Has the dog(s) ever bitten anyone? Yes No
Type: Shown aggressive behavior? Yes No
Custom spraying involved? Yes No H. In what condition are the applicant’s fences? Good Fair Poor
Gross annual custom farming receipts? I. Do all steps have adequate handrails? Yes No
C. Are premises used for any business or professional purposes
other than farming? Yes No If Yes, explain: J. Condition of farm equipment: Good Fair Poor
Has safety equipment been altered or removed? Yes No
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7. Other Insurance:
A. Is there other insurance? Yes No If Yes, with whom?
B. Is there other insurance with RAM? Yes No If Yes, policy number:
8. How long has agent personally known applicant?
Does agent personally recommend issuance of this policy? Yes No
9. Other information:
Special Restrictions:
Applicant’s Signature:
Loss History - List ALL losses, at this or any other location, within the last three (3) years or any loss ever if over $10,000.
List dates, type, and amount: None
PREVIOUS CARRIER (at this or prior location):
Was policy cancelled or non-renewed? Yes No
Explain:
Initials of Insured (REQUIRED):
GENERAL AGENTS USE ONLY
Application has been reviewed and approved. GA’s initials:
Agent
and
Address
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CODE AMOUNT DESCRIPTION Fire/Wind
CODE AMOUNT DESCRIPTION Fire/Wind
CLASS A-1 DWELLINGS - Photos Required Dwelling Replacement Cost and Coverage Adjustment is included
Class A-1 Basic Broad Special
Superior A-1 Special ______ _______ $ _____________________ Residence ______ _______ $ _____________________ Household Personal Property ______ _______ $ _____________________ Increase in Living Costs ______ _______ $ _____________________ ________________________ $ _____________________ Sub-Total
Protected Partially Protected Unprotected
OPTIONAL COVERAGES
Special Form Unscheduled Personal Property Replacement Cost - Household Personal Property
CLASS A-2 DWELLINGS - Photos Required
Limited Basic Broad ______ _______ $ ______________ Dwelling ______ ______x____x______ ______ _______ $ ______________ Household Personal Property ______ _______ $ ______________ Increase in Living Costs ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total
CLASS A-3 MOBILE HOMES - Photos Required
Limited Basic Broad ______ _______ $ _________ Home (Age/Make) ________ ______x____x______ ______ _______ $ _________ _____________________ ______x____x_____ ______ _______ $ _________ Additions ____________ ______x____x______ ______ _______ $ _________ Household Personal Property ______ _______ $ _________ Increase in Living Costs ______ _______ $ _________ _____________________ ______x____x______ $ _________ Sub-Total
CLASS E SCHEDULED FARM PERSONAL PROPERTY Includes 7B Non-depreciation of Repairs
Limited Basic Broad
______ _______ $ ________ Scheduled Farm Personal Property (From 7 on pg. 7) ______ _______ $ ________ Portable Crop or Grain Dryer (515) ______ _______ $ ________ Farm Operations Record Expenses (533) ______ _______ $ ________ ______________________________________ $ _________ Sub-Total
CLASS F UNSCHEDULED FARM PERSONAL PROPERTY Includes 7B Non-depreciation of Repairs
Limited Basic Broad Special
Code ________ _________ $ ___________________ Unscheduled Farm Personal Property (From 8 on pg. 7)
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CLASS G-1 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required
Superior - Minimum of 80% of Replacement Cost Replacement Cost, Special Form, Opt. Cov. P, & Coverage
Adjustment Incl. ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______
G-1S (Asphalt Shingles)
______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total
CLASS G-2 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required
(Includes Opt.Cov. P) Minimum of 50% of Replacement Cost
Above Average - ACV basis
Limited Basic ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total
CLASS G-3 FARM BARNS, BUILDINGS, STRUCTURES & OUTBUILDINGS - Photos Required
Minimum of 25% of Replacement Cost Standard - ACV basis
Limited Basic ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total
CLASS H SPECIAL HAZARDS - Photos Required
Limited Basic ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ ______ _______ $ ______________ _____________ ______x____x______ $ ______________ Sub-Total
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MISCELLANEOUS PROPERTY ACORD Form Required on All Commercial Property Check company manual for rules and binding authority.
Code ______ _______ $ ______________ _____________ ______x____x______
Code ______ _______ $ ______________ _____________ ______x____x______
Code ______ _______ $ ______________ _____________ ______x____x_____
$ ______________ Sub-Total
SEGAREVOC LANOITPO )ylnO egarevoC MT( SEGAREVOC LANOITPO
______ ______ Yes No $____________ Add’l Fire Dept. Service ______ ______ Yes No $____________ Peak Season - Item:
______ ______ Yes No $____________ Submersible Pumps
From: To:
______ ______ Yes No $____________ Underground Wiring ______ ______ Yes No $____________ Loss of Income
(Dairy & Hogs)
______ ______ Yes No $____________ Theft Coverage Extension ______ ______ Yes No $____________ Farm Extra Expense
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Blizzard Death
(Livestock) (RAM)
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $_________ Livestock Confinement (RAM)
(Separate RAM application required)
DO NOT BIND
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Special Form -
Farm Machine (RAM)
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Leased, Rented, or
Borrowed Farm Machinery Coverage
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ Equipment Breakdown TM114
______ ______ Yes No $____________ _____________________ ______ ______ Yes No $____________ _____________________
______ ______ Yes No $____________ _____________________
______ ______ Yes No $____________ _____________________
$ ______________ Sub-Total $ ______________ Sub-Total
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Class
FARM PERSONAL PROPERTY INVENTORY SCHEDULED FARM PERSONAL PROPERTY UNSCHEDULED FARM PERSONAL PROPERTY
TOTAL SCHEDULED VALUE TOTAL UNSCHEDULED VALUE
(Add 1 through 6 - transfer amount to page 2) $____________ (Add 1 through 5 - transfer amount to page 2) $___________
Comments: _______________________________________________________________________
Policy provisions require individual scheduling of above items when not being used in Unscheduled Farm Personal Property. The following items may be optionally scheduled.
Item (Describe) Value
TRACTORS (505) No. 1 _________________ $ _________ No. 2 _________________ $ _________ No. 3 _________________ $ _________ No. 4 _________________ $ _________ Garden Tractor _________ $ _________ Skid Loader ___________ $ _________ _____________________ $ _________ Combine No. 1 (505) ____ $ _________ Combine No. 2 (505) ____ $ _________ Combine Heads ________ $ _________ Swather ______________ $ _________ Picker/Sheller (505) _____ $ _________ Other Self-propelled (505) $ _________ _____________________ $ _________ _____________________ $ _________ Port. Elevator __________ $ _________ Port. Auger No. 1 (505) __ $ _________ _____________________ $ _________ Port Auger No. 2 (505) ___ $ _________ _____________________ $ _________ Bale Racks & Trailers ____ $ _________ Beet Defoliators ________ $ _________ Beet Lifters ____________ $ _________ Beet Thinners __________ $ _________ Chisel Plow ____________ $ _________ Corn Planter ___________ $ _________ Crop Sprayer __________ $ _________ Drill Seeder ____________ $ _________ Disc __________________ $ _________ Drag _________________ $ _________ Fert. Spreader _________ $ _________ Field Cultivator _________ $ _________ Grain Wagons _________ $ _________ Grinder/Mixer/Mill _______ $ _________ Hay Baler _____________ $ _________ Hay Crimper ___________ $ _________ Hay Stacker/Loader _____ $ _________ Hay Stack Mover _______ $ _________ Livestock Trailer (Unlicensed)$ _________ Mach. Trailer (Unlicensed) __ $ _________ Manure Spreader _______ $ _________
LIVESTOCK Number Value Total
CATTLE (514) Dairy Cows ______ @ ______ $ _________ Heifers ______ @ ______ $ _________ Calves ______ @ ______ $ _________ Feeder Cattle ______ @ ______ $ _________ Stock Cattle ______ @ ______ $ _________ Bulls ______ @ ______ $ _________ Registered Cattle ______ @ ______ $ _________
SHEEP (514) Ewes ______ @ ______ $ _________ Rams ______ @ ______ $ _________ Lambs ______ @ ______ $ _________
HOGS (514) Sows ______ @ ______ $ _________ Boars ______ @ ______ $ _________ Feeder Pigs ______ @ ______ $ _________
HORSES (514) ______ @ ______ $ _________
TOTAL LIVESTOCK ………………… $ _________
POULTRY Hens (514) ______ @ ______ $ _________ Fryers ______ @ ______ $ _________
TOTAL POULTRY …………………… $ _________
HAY, STRAW, & FODDER Hay (522) ______ @ ______ $ _________ Straw ______ @ ______ $ _________ Fodder/Silage ______ @ ______ $ _________
TOTAL HAY, STRAW, & FODDER: $ _________
GRAIN, FEED, & SUPPLIESCorn (521) ______ @ ______ $ _________
Soybeans ______ @ ______ $ _________ Wheat ______ @ ______ $ _________ Oats ______ @ ______ $ _________ Sunflowers ______ @ ______ $ _________ Farm Chemicals ______ @ ______ $ _________ Veterinary Supplies ______ @ ______ $ _________ Fuel Oil & Grease ______ @ ______ $ _________ Paints ______ @ ______ $ _________ Commercial Feed ______ @ ______ $ _________ Ground Feed ______ @ ______ $ _________ _____________ ______ @ ______ $ _________
TOTAL GRAIN, FEED, & SUPPLIES $ _________
Item (Describe) Value
Mower _____________ $ ________ Plows _____________ $ ________ Potato Digger _______ $ ________ Rakes _____________ $ ________ Rotary Tiller/Hoe _____ $ ________ Row Cultivator _______ $ ________ Silage Wagon _______ $ ________ Silage Cutter/Blower __ $ ________ Stalk Cutter _________ $ ________ Snow Blower ________ $ ________ Spraying Tank _______ $ ________ Tractor Loader ______ $ ________ Vaculator ___________ $ ________ Other Farm Mach.(505)$ ________ __________________ $ ________ __________________ $ ________ __________________ $ ________
TOOLS & MISCEQUIPMENT (506)
Electric Motors ______ $ ________ Fuel Tanks _________ $ ________ Port. Generator ______ $ ________ Spare Parts _________ $ ________ Power Tools ________ $ ________ Hand Tools _________ $ ________ Welder _____________ $ ________ Compressor ________ $ ________ Bldg/Fencing Material _ $ ________ __________________ $ ________ __________________ $ ________
TOTAL FARM MACHINERY & EQUIP. $ ________
1
2
3
4
5
INSTALLED EQUIPMENT (591)
(Must be scheduled to be insured)
Bulk Tank/Cooler $ ________ Crop or Grain Dryer $ ________ Milk House Equip. $ ________ Milking Machine (Port)$ ________ Hog House Equip. $ ________ Poultry Equipment $ ________ Silo Unloader $ ________
TOTAL INSTALLED EQUIPMENT $ ________ 6
8 7
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FARM MACHINERY & EQUIPMENT
SCHEDULE OF ANNUAL LIABILITY RATES
COVERAGE APPLIES?
Yes No
CODE # DESCRIPTION PERSONAL LIABILITY
50,000 100,000 300,000 500,000 1,000,000
MEDICAL PAY
Add’l for each
$1,000 (max
$5,000)
PREMIUM
FCPL-1A Farmers CPL (FCPL)
sercA 023 ot pu ,sgnidliuB fo teS 1 ,gnillewD 1
Additional Acreage Charge
sercA 000,1 ot 123 6109
9017 Over 1,000 Acres
CPL-1A Personal Liability (CPL) Up to 40 Non-Farm Acres
Additional Acreage Charge
sercA mraF-noN 08 - 14 5109
L9105 Additional Named Insured - Premises Only Liability
L9106 Additional Named Insured - Personal Liability
CF108 Additional Residence Premises - Rented to Others
One Family
Two Family
CF109 Additional Residence Premises
9225 Additional Set of Buildings
CF71 Business Activities
L9186 Custom Farming: Rates per $100 of receipts Apply only if receipts exceed $1,000; rate then applies to all receipts
L9996 Damage to Property of Others (Coverage N) $500 included in policy-max Limit $10,000 - each additional $1,000 is $7
L9300 Employers’ Liability If payroll is between $8,000 and the amount required by MN Comp Law for Work Comp
L6123 Family Med. Pay Ages 12-65 only ($100 Deductible)
9023 Inactive Farmer Credit - N/A with CPL
9024 Hobby Farm Credit - N/A with CPL
Horse Exposure Charge
9231 □ 1-2 Horses 9232 □ 3-5 Horses 9233 □ 6-10 Horses
9235 Limited Non-Owned Horse Exposure 1-10 Horses. Rate applies to each horse.
9020 Livestock Exposure Charge
CF107 Office, Professional, Private School, or Studio Use
CF106 Personal Injury (No Medical)
L9125 Property in Control of Insured (Fire Legal Liability - Farm Premium) $10,000 included in policy. Each add’l $5,00 is $2.
CF105 Recreational Vehicles (Off Premises) (Fully Earned)
CF110 Watercraft Liability (Motors Over 100 HP)
CF110J Jet-Driven Watercraft
Other:
TOTAL
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AGREEMENT AND SIGNATURE OF APPLICANT AND AGENT
The signatures below certify that:
1. all property under Class E is listed to at least 80 percent of actual cash value.
2. Class F property is insured to 100 percent of the Inventory Schedule. The applicant understands that an 80 percent coinsurance requirement applies and agrees to, at all times, maintain contributing insurance on the property insured to the extent of at least 80 percent of its actual cash value, and failing to do so, shall to the extent of any deficit bear the proportion of any loss.
3. all Class G-1 structures are insured to at least 80 percent of replacement value.
4. all Class G-2 structures are insured to at least 50 percent of replacement value.
5. the Farm Personal Property inventory contains a full description of the total values of the property listed.
6. the answers to questions on this application are true, correct, and complete representations.
7. as the applicant for this insurance, I grant permission to the underwriting department of RAM Mutual or Palo Mutual to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit, character, and/or condition of the property represented on this application. 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 appeal to the Commissioner (Director) (MN) - Minnesota Commission of Commerce, 85 - 7th Place East, Suite 500, St. Paul, MN 55101-2198. If this application for insurance is accepted, I grant permission to RAM Mutual or Palo Mutual to disclose information to the mortgagee(s) or loss payee(s) that may be designated in this application or its (their) successor(s) Reports prepared by insurance-support organizations may be retained by them and disclosed to others.
8. the check box “Yes/No” areas accurately indicate desired coverage.
9. 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. Loss History is correct. ________
APPLICANT’S SIGNATURE: DATE:
AGENT’S SIGNATURE: DATE:
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WORKSHEETPREMIUM COMPUTATION FIRE
Class Insurance Amount Rate Premium Premium Premium Total
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WIND
FIRE WIND
Class Insurance Amount Rate Premium Premium Premium Total
OPTIONAL COVERAGES: List and Describe
Total Insurance Coverage Total Wind Premium
Total Fire Premium Wind Zone Adj.
Liability Premium
Total Fire Premium
Farm Partner Plus 5% max (Member Company Only) Inland Marine
Continuous Coverage Credit (5%) max Credits/Surcharges
Total Policy IRPM % Surcharge
Yes No
Q Added Perils for Refrigerated Food Products (TM Only)
6J Agreed Percentage Replacement Cost for Dwellings
7S Amended Theft
6R Cab Glass - Scheduled
7A Collapse - Weight of Ice, Snow, or Sleet
7Q Collapse - Weight of Ice, Snow, or Sleet
7W Collision and/or Overturn
7Y Collision and/or Overturn
6S Debris Removal
W Deferred Loss Payment
R Glass Coverage - Unscheduled $ Ded.
T Farm Extra Expense
7X Expanded Vehicle Damage
7H Earthquake
X Deferred Loss Payment
X
Yes No
SPC Special Package of Coverages - RAM (included)
SPC Special Package of Coverages - TM
7P Leased, Rented, or Borrowed Farm Machinery, Vehicles
& Equipment of Others
6T Loss of Income or Rent
7N Loss of Income
7R Loss of Use or Income
S Peak Season Inventory
K Replacement Cost Endorsement - Household
Personal Property
7U Backup of Sewers, Drains, or Sump Systems
7J Theft Coverage Extension
V Restriction of Individual Policies
Y Replacement Cost Provision
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