30 BULLETIN 530, U. S. DEPARTMENT OF AGRICULTURE. 



Form for application. 



APPLICATION. 



I, the undersigned, owner of the property hereinafter enumerated and described, located on the « 



i of the i of section of township, County, in the State of , hereby apply to 



the Farmers' Mutual Fire Insurance Company for insurance on said property in the respec- 

 tive sums Indicated, said insurance to be in effect from "the day of , 19l". ., at noon, to 



the day of , 192. ., at noon. 





Value. 



Insur " Class 

 ance. p idss - 



Dwelling built of , with roof, in repair; rodded? 





















































| 









































































































Bam built of , with roof, in repair; rodded? 

















Silo with contents, diameter .... ft., height ft., in repair 



























































Further descriptions: 



/— main part, ft. by ft., ft. posts, stories, built 



in ; with wing or attachment ft. by ft., .... ft. posts, 



-built in ; finished rooms , unfinished rooms ; foundation 



; number of chimneys ; material , resting how? ; 



are stove pipes properly insulated where passing through partitions or 



ceilings? ; disposition of ashes ; lighting system ; 



occupied by 



Granary — main part, ft. by ft., ft. posts, built in ; 



with attachment or lean-to ft. by ft., ft. posts, used for 



Barn — main part, ft. by ft., 



attachment or lean-to ft. by 



... ft. posts, built in ; with 



ft., ft. posts, used for 



Insur- 

 ance by 

 class. 



- Class 

 and rate. 



Initial 

 premium. 





A . 15 

 B .20 

 C .25 

 D .33 

 E .40 



























Totals. 





1 





I hereby accept and subscribe to the articles of incorporation and the by-laws of the 



Farmers' 

 Mutual Fire insurance Company, and in consideration of the above-stipulated insurance bind myself, 

 my heirs and assigns, to pay my pro raia share of all losses and legitimate expenses incurred by said 

 company while said insurance "remains in force. I also alfirm that the valuations, statements, and 

 descriptions given in this application, are to the best of my knowledge and belief, corred . 



Signed: 



Dated this day of 



191. 



