- 1 -CF-346 (Ed. 4-17)

Actual Loss sustained in 12 months

GENERAL AGENT’S USE ONLY GA's Initials_______ Application has been reviewed and approved.

CDO - PACKAGE HOMEOWNER’S APPLICATION Company 1 - TOWNSHIP MUTUAL Company 2 - STATEWIDE MUTUAL

Fire Policy #:_________________________________

APPLICANT: _________________________________________ AGENCY: CODE: ___________ WIND CO. USEAddress: ____________________________________________ _______________________________________________ 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: ___________, Sec.______, Twp.______, Range_______, Twp_________________,_______________County, MN, Rural Fire # _________

POLICY TYPE: PRIMARY RESIDENCE SEASONAL RESIDENCE CONDOMINIUMPERILS: 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. 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)

BILLING MODE: Annual Semi-Annual Quarterly Other__________ BILL PREMIUM TO: Insured  Agency Escrow/Direct Bill ONLY PREMIUM SECTION Co. One Co. Two CombinedBasic Charges: .................................................................................................................................... DISCOUNTS Yes No Auto Companion Discount Policy # _________________________________ ________________________________________ Yes No New/Upgraded Home Component Discount ......................................................... ________________________________________ Yes No Metal Roof Discount (Cosmetic Damage Exclusion applies) ................................ ________________________________________ Yes No Other: List: _____________________________________________________ ________________________________________OPTIONAL COVERAGES: Property Yes No Replacement Cost - Household Personal Property .............................................. ________________________________________ Yes No Special Form - Household Personal Property ....................................................... ________________________________________ 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: ___________________________________________ ________________________________________ Yes No Underground Service Line Coverage .................................................................... ________________________________________ 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 Premises................................................................... __________________________ Yes No Additional Residence Maintained .......................................................................... __________________________ Yes No Additional Residential Premises Rented To Others .............................................. __________________________ No. of Families:__________ Location: _______________________________ Yes No Business Activities: Type: _________________________________________ __________________________ Yes No Care Provided For Others: .................................................................................... __________________________ 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 Liability ................................................................................................. __________________________ Yes No Other: List: _____________________________________________________ __________________________OPTIONAL COVERAGES: Inland Marine (complete page 3) Yes No ..............................................................................................................................

TOTAL PREMIUM $ $ $

Requested Effective Date:

_______________________________12:01 a.m. standard time at location described

New

Renewal of:__________________

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PROPERTY UNDERWRITINGDrivers License: Appl.: _________________________ Spouse: ______________________ Other policies with either carrier? Yes NoSocial 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 HydrantProtective Devices - Premium Credits:___________________ 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.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 Average1. Heating: Age:______ Type:______ Condition:_________________ Central: Yes No 2. Wiring: Age:______ Type:______ Condition:_________________ Amps:___________ Rewired: Completely Partially 3. Plumbing: Age:______ Type:______ Condition:_________________ 4. Siding: Age:______ Type:______ Condition: ______________________________5. Roof: Age:______ Condition: ____________________________________________________________________________________________________ Type: Asphalt Shingles Wood Shakes or Shingles Metal 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 4OTHER STRUCTURES UNDERWRITINGAll 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: ______________ 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)SPECIAL RESTRICTIONS: PH900 or PH901 Actual Cash Value Shingles CF-1742 Actual Cash Value Exterior SurfacesOther: _________________________________________________________________________________________________________________________________________________________________________________________________________________

LIABILITY UNDERWRITINGIs there a Trampoline? Yes No Is there a Swimming Pool on premises? Yes No Type____________ Diving Board or Slide? Yes No Is there a fence around the pool? Yes NoDoes applicant own Dog(s)? Yes No #:________ What Breed(s)?__________Has Dog(s) ever bitten anyone? Yes NoIs there Day Care Exposure? Yes No If Yes, how many children?____________Policy #___________________________________Do all Steps and Deck Structures have adequate railings? Yes NoHorses? 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 PoorAny 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.)

Applicant'sInitials

Applicant'sInitials

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OPTIONAL INLAND MARINE COVERAGES AND UNDERWRITINGSCHEDULED PROPERTYSCHEDULE OF ARTICLES TO BE INSURED. (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: 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/OBOAT Outboard I/OPERSONAL WATERCRAFT XX XXMOTOR #1 XX MOTOR #2 XXTRAILER XX XX XX BOAT LIFTS DOCKS XX XX XXFISH LOCATORS XX XX XXOTHER_________________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. Col- Non- Comp. Ins. - 100% Vehicle Built and Model CC's Number Speed Price lision Dep. Ded.* Rate to Value Prem.

NOTE: * Minimum collision deductible on snowmobiles is $500. Collision Coverage is not bound on used/pre-owned snowmobiles unless a photo of the machine and a statement that a visual inspection has verified no existing damage.

SOLID FUEL BURNING APPLIANCE CHECKLISTGENERAL (Attach Photo) 1. Unit is a: Circulating Stove Radiant Stove Free-Standing Fireplace Fireplace Insert Barrel Stove

Wood/Oil Combination Wood/Gas Combination Corn Other: __________________________ 2. Manufacturer:__________________________________________ Age:______ Is unit UL approved? Yes No 3. Installed by: Contractor Insured/Applicant Other: _________________________________________________ 4. Inspected by:______________________________________________________________ Date inspected: __________________________ 5. Use: Primary Heat Source Supplemental Heat Cooking Other: ____________________________________ 6. Is unit ever operated while unattended? Yes No If Yes, explain: ______________________________________________ 7. Location of unit? ____________________________________________________________________________________________________CLEARANCES/PROTECTION 1. Distance from stove pipe to nearest wall or ceiling is __________ inches. 2. Distance from unit to nearest wall or furnishing is __________ inches. 3. Is wall and/or ceiling protection provided? Yes No If Yes, describe: ___________________________________________ 4. Distance from bottom of unit to protective floor covering is __________ inches. 5. Protective floor covering extends __________ inches beyond front of unit. 6. Protective floor covering extends __________ inches beyond rear of unit. 7. Protective floor covering extends __________ inches beyond each side of unit.CHIMNEY CONNECTOR 1. Stove Pipe: Length__________ Diameter__________ Number of Elbows__________ Gauge of Metal__________ 2. Does stove pipe reduce in size from stove pipe to chimney? Yes No 3. Does stove pipe include any heat saving devices? Yes No If Yes, explain: ________________________ 4. Does stove pipe pass through any wall or ceiling before entering chimney? Yes No

If Yes, describe wall pass-through: ______________________________________________________________________________________ 5. Stove pipe enters chimney through: Clay Thimble Double Wall Insulated Pipe Other: __________________________ 6. How are stove pipe sections joined or fastened? ___________________________________________________________________________ 7. Does horizontal stove pipe rise at least 1/4 inch per foot towards the chimney? Yes No 8. If a fireplace insert: Describe connection to the chimney flue: ________________________________________________________________

Has existing chimney damper been blocked open or removed before installing the insert? Yes NoCHIMNEY 1. Masonry - type of flue liner: ________________________________________________________________________________________

Factory built “all fuel” - Manufacturer/Model:___________________________________________ UL approved? Yes NoOther: ________________________________________________________________________________________________________

2. Does chimney flue serve any other appliance? Yes No If Yes, explain: __________________________________________ 3. Distance chimney extends from top of roof: _______________________________________________________________________________

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ADDITIONAL INTERESTS: First Mortgagee Second Mortgagee OtherName: ________________________________ ________________________________ _________________________________Address: ________________________________ ________________________________ _________________________________Address: ________________________________ ________________________________ _________________________________Loan/Acct #: ________________________________ ________________________________ _________________________________

MUST BE READ AND SIGNED BY APPLICANT AND AGENTThe signatures below certify that:1. The answers to questions on this application are true, correct and complete representations.2. Unless indicated on this application, the applicant agrees that: (a) the described dwelling is not seasonal; (b) no business pursuits are conducted on the described premises; (c) the described

premises is the only premises where the named insured or spouse maintains a residence other than business or farm properties; and (d) the insured has no full-time residence employee(s).3. The applicant agrees inflation protection will be a part of the policy and that property limits may be increased annually to keep pace with construction costs.4. As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting departments of the Township Mutual listed on the front and 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. I understand that I have the right to make a request in writing as to the nature of any such information that may bedeveloped 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 thatI have the right to appeal to the Minnesota Commissioner of Commerce, 85 7th Place East, Suite 500, St. Paul, MN 55101-2198). I understand that this temporary authorization willexpire as soon as one of the following occurs: (a) The above named companies make the underwriting decision(s) in question, or (b) one year elapses after the date I sign thisauthorization. However, if a policy is issued, 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 the Township Mutual and North Star Mutual to disclose information to the Mortgagee(s) or Loss Payee(s) that maybe designated in this application or its(their) successor(s). (Reports prepared by insurance-support organizations may be retained by them and disclosed to others.)

5. 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.THE INSURER MAY ELECT TO CANCEL COVERAGE AT ANY TIME DURING THE FIRST 59 DAYS FOLLOWING ISSUANCE OF THE COVERAGE FOR ANY REASON WHICH ISNOT SPECIFICALLY PROHIBITED BY STATUTE.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 ________________________