Forms Listing - North Star Mutual Insurance Company

CPP FORMS - MNFORM NUMBERS &EDITION DATES COMP. TITLECOMPUTER GENERATED CPP DECLARATIONSL 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 willnot use SPC but will instead use NS-781B.)V 1-13 MAFMIC RESTRICTION OF INDIVIDUAL POLICIESW 1-13 MAFMIC DEFERRED LOSS PAYMENTX 1-13 MAFMIC DEFERRED LOSS PAYMENTY 1-13 MAFMIC MODIFIED REPLACEMENT COST PROVISION EXPANDED COVERAGEDWELLING (Coverage A)TP1 1-13 MAFMIC STANDARD POLICY – TABLE OF CONTENTS, AGREEMENT, POLICYPERIOD, GENERAL POLICY PROVISONS, DEFINITIONS, PRINCIPALPROPERTY COVERAGES AND EXCLUSIONS, INCIDENTAL PROPERTYCOVERAGES, PERILS WE INSURE AGAINST AND EXCLUSIONS,GENERAL EXCLUSIONS, PROPERTY NOT COVERED, HOW MUCH WEPAY FOR LOSS OR CLAIM, DUTIES AFTER LOSS, PAYMENT OF LOSS ORCLAIM, POLICY CONDITIONS, AND OPTIONAL COVERAGESThe 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 orF)T MAFMIC FARM EXTRA EXPENSE (Coverage E, F, or G)U MAFMIC RECREATIONAL EQUIPMENT7U MAFMIC BACKUP OF SEWERS, DRAINS OR SUMP SYSTEMS (THIS IS NOT FLOODINSURANCE) (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 ADJUSTMENT6S MAFMIC DEBRIS REMOVAL (Coverage A, C, E, F, or G)7W MAFMIC EXPANDED COLLISION AND/OR OVERTURN – PLUS (Coverages E and F)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) Providedby the Statewide Mutual Company.6P MAFMIC LIVESTOCK CONFINEMENT COVERAGE (Coverage E or F) Provided bythe Statewide Mutual company.6R MAFMIC SCHEDULED CAB GLASS (Coverage E or F)7X MAFMIC EXPANDED VEHICLE DAMAGE Provided by the Township Mutual.PDN TP1 1-13 MAFMIC POLICY DISCLOSURE NOTICE (Do not show form number or edition date on theDeclarations. Use to notifyhttp://www.northstarmutual.com/userfiles/documents/forms/policyforms/currentpolicyholder of changes that have been made to the TP1. To be sent with existing policiesthe first time they renew with the TP1 1-13)6L 4-15 MAFMIC AMENDATORY ENDORSEMENTPage 1 of 3

CPP FORMS - MNFORM NUMBERS &EDITION DATES COMP. TITLE6M 4-15 MAFMIC EXCLUSION OF LOSS DUE TO BY-PRODUCTS FROM PRODUCTION ORPROCESSING PRODUCTSPDN-6M 4-15 MAFMIC POLICYHOLDER DISCLOSURE NOTICE (Exclusion of Loss due to By-Products from Production or Processing Products)6Q 1-13 MAFMIC SPECIAL EXTENSION OF COVERAGE FOR LIVESTOCK (Coverage E or F)Provided by the Township Mutual.6T 1-13 MAFMIC LOSS OF INCOME OR RENT (Coverage E, F or G)6W 1-13 MAFMIC DEFERRED LOSS PAYMENT6X 1-13 MAFMIC DEFERRED LOSS PAYMENT7A 1-13 MAFMIC COLLAPSE – WEIGHT OF ICE, SNOW OR SLEET (Coverage E or F)Provided by the Township Mutual.7AI 1-13 MAFMIC ADDITIONAL INSUREDS7C 1-13 MAMFIC AMENDED VANDALISM OR MALICIOUS MISCHIEF AND THEFT EXPANDEDCOVERAGE Provided by the Township Mutual.7D 1-13 MAFMIC AMENDED VANDALISM OR MALICIOUS MISCHIEF EXPANDED COVERAGEProvided by the Township Mutual.7H 1-13 MAFMIC EARTHQUAKE Provided by the Township Mutual.7J 1-13 MAFMIC THEFT COVERAGE EXTENSION CONSTRUCTION MATERIALS ANDSUPPLIES (Coverage A or G) Provided by the Township Mutual.7LF 4-15 MAFMIC LIMITED FUNGUS, BACTERIA, WET ROT, OR DRY ROT COVERAGEPDN-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 farmingoperation)7P 1-13 MAFMIC LEASED, RENTED OR BORROWED FARM MACHINERY, VEHICLES andEQUIPMENT (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 COVERAGEPDN-8TL 1-15 MAFMIC POLICYHOLDER DISCLOSURE NOTICE – NOTICE OF TERRORISMCOVERAGE8TL 01-15 MAFMIC CERTIFIED TERRORISM LOSS COVERAGE/NON-CERTIFIED TERRORISMLOSS EXCLUSION/NUCLEAR, BIOLOGICAL, CHEMICAL ANDRADIOLOGICAL EXCLUSION/WAR AND MILITARY ACTION EXCLUSIONTP10 03-03 MAFMIC NOTICE OF CANCELLATION OR NON-RENEWALTP-10R 12-03 MAFMIC NOTICE OF CANCELLATION OR NON-RENEWAL (RAM Mutual uses this)TP12 03-03 MAFMIC NOTICE OF CANCELLATION NON-PAYMENTTP12R 12-03 MAFMIC NOTICE OF CANCELLATION NON-PAYMENY (RAM Mutual uses this)NS-25 09-09 NSM CONSENT TO MOVE MOBILE HOMENS-26 09-09 NSM COLLISION OR OVERTURN OF MOBILE HOMENS-27A 1-13 NSM SECURED PARTY'S INTEREST COVERAGE (Basic)NS-28A 1-13 NSM SECURED PARTY'S INTEREST COVERAGE (Comprehensive)NS-0420 3-11 NSM INSTALLED EQUIPMENT BREAKDOWN COVERAGECF-580 11-13 NSM PREFERRED DWELLING SUPPLEMENTAL APPLICATIONCF-592 8-10 NSM LIVESTOCK CONFINEMENT COVERAGE SUPPLEMENT APPLICATIONNS-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 ENDORSEMENTCF-1000 4-13 NSM COMBINATION PACKAGE APPLICATIONCF-1000a 4-13 NSM PREMIUM COMPUTATION AND WORKSHEET/CLASS G SCHEDULECF-1008 4-13 NSM FARM PERSONAL PROPERTY INVENTORYPage 2 of 3

CPP FORMS - MNFORM NUMBERS &EDITION DATES COMP. TITLECF-1098 1-13 NSM LOSS OF INCOME (POULTRY BUILDINGS)Page 3 of 3

CPP FORMS - MNFORM NUMBERS &EDITION DATES COMP. TITLENSCF-1243 8-11 NSM NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCYUNDER THE MINNESOTA INSURANCE GUARANTY ASSOCIATION LAW(MN) (We rely on the Agents to give a copy of this notice to the applicant when anapplication is taken. The notice must be given in writing or in the same medium as theapplication for insurance. This notice would only be attached to renewal certificates if therenewal increases the dollar amount of a coverage by more than 100%) (The NSCF-1243 willnot show on the dec!)CF-1297 1-13 NSM DELUX DWELLING PLUS ENDORSEMENTCF-1358 1-13 NSM SPECIAL FORM - DEDUCTIBLE AND ADDITIONAL PROVISIONAPPLICABLE TO FARM PERSONAL PROPERTY Applies to North StarMutual.CF-1545 9-09 NSM ACTUAL CASH VALUE LOSS SETTLEMENT WINDSTORM OR HAILLOSSES TO ROOFS Applies to the North Star Mutual.CF-1694 10-02 NSM THE NORTH STAR MUTUAL COMMITMENT TO PRIVACY (Send with newpolicies and renewals. 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 formnumber or edition date on Declarations. Send with policy whenever the CF-1545 [ACV LossSettlement Windstorm or Hail Losses to Roof] is attached to a CPP policy for the first time.)Applies to the North Star Mutual.CF-1859 8-08 NSM IDENTITY THEFT AND IDENTITY FRAUD EXPENSE INFORMATION SHEET(Send with new policies and renewals. This has to be sent annually) (CF-1859 will not showon the Dec!)CF-1908 1-10 NSM CPP POLICY JACKETCF-2018 1-13 NSM COSMETIC DAMAGE EXCLUSION (cosmetic damage caused by hail) (appliesto Farm Barns, Buildings, Structures & Outbuildings) Applies to North StarMutualCF-2058 4-13 NSM COSMETIC DAMAGE EXCLUSION (applies to Dwellings) Applies to NorthStar MutualNS-2786 8-06 NSM IDENTITY FRAUD EXPENSES Provided by North Star MutualFARM/PERSONAL LIABILITY FORMSFor liability forms that can be added to the CPP policy, see the Farm Personal Liability/Personal Liability Formslisting (FORM LISTS\FORM LISTS -HTTP://WWW.NORTHSTARMUTUAL.COM/USERFILES/DOCUMENTS/FORMS/POLICYFORMS/CURRENT\PLFILE).INLAND MARINE FORMSFor Inland Marine Forms that can be added to the CPP policy, see the Inland Marine Forms Listing. (FORMLISTS\FORM LISTS -HTTP://WWW.NORTHSTARMUTUAL.COM/USERFILES/DOCUMENTS/FORMS/POLICYFORMS/CURRENT\IMFILE)Page 4 of 3