A FARMERS MUTUAL FIRE INSURANCE COMPANY. 

 Form for outside of application: 



Number 



APPLICATION 



for 

 Insurance in the 



Farmers' Mutual 



Fire Insurance Company 



of 



made by 



Name of applicant. 



Address. 



Amount of insurance 

 Policy fee 

 Initial premium 



Total 



Agent's approval: 



This application has my approval. 



Full or conditional. 



Signed 



Title 



Note. — If your approval is conditional, be sure to give your 

 reasons in a letter to accompany the application. 



Officially -«g«l and ordered ^raed thi 



day of 



., 19L, 



Secretary. 



29 



