30 
Form for application. 
APPLICATION. 
I, the undersigned, owner of the property hereinafter enumerated and described, located on the 
BULLETIN 530, U. S. DEPARTMENT OF AGRICULTURE. 
3 
4 of thee tot section 22-- Of 2s. -e township, ....-- County, in the State of ...... , hereby apply ia 
the ————~— Farmers’ Mutual Fire Insurance Company for insurance on said property in the respece 
tive sums indicated, said insurance to be in effect from the ...... Gays Ofmeresee , 191.., at noon, ta 
Gheses..< GayxOlteriiercc , 192.., at noon. 
7 Insur- | 
Value. ace ne 
Dwelling built of ...... , With s2.5.3 POOL, ieee pOpair; TOME face ees seer ee ee eee ae | oe ts 
Household goods in dwelling BAA SAE AS en pe Sa scSouoeaEnapesocaae Suaccmoersclosccaaséedlasouodsonclsa-es- 
Wearing apparelin dwelling. .--...-.-..-.--.+------2+ +022 eee e ee eee ee ee ee] eee e ee ee] eee eee] ee eee 
12 oar cai hy Keb bho ga nrc Sane ao ose GoddGO Nb UGE ao Senco 5500 Conds 700550 bono co oosG|Ssodatesccilessace 
Musical instruments in dwelling, as follows:..........220...2200eeeeeee ee eeeee Sea CS ee gee | eee 
Summer kitchen ’.-. ft. by ....ft.,....4t. posts, im... repair) 8 ee Jue sl tense 59) se eeet et agent 
Wood house .... ft. by ....ft., .... mitt posts, in .... repair.....-..--.--------|20 2-222 -e-| 2 fee eee 
Granery built of ....-. awit hie sate roof,in...... repairsrodded? 2.2.) 1ch.05 het oa eee ee 
Contents of above-mentioned granary <-22. 34s = ace aise eee eee Eee ene Eee eer te eee eee See 
Com crib .... ft. by ....4t., -... it. posts, im. .2 onepalr:s.05- 5 ye seeks Gl ue el (ee 
@ontents of above-mentioned corncrib ©: 2 sus 2c dak seca eet meee ert ee ee 
omhouse / 6) ttibys, . tt ck.c ft. posts, im... repairs... 22s. s sees) ceseeeeee| eee ooo 
Machine shed «<p. Sak ok .c See Ee aC eee eee ie ae sieeeteel |e Betas Senne ope 
Harm imi plementsiand Cools <7. .5) «ore ciao: 3 wie ye ie sape ea retw oyeam = oye ae ee aera tee eee eae eee ele 
Wagons; carriages, ‘and harness: . 2... soso 2 one watts eyes eel oe ere ater | Ge ere | eee 
liorsesiandanulless mum ber 2: ses pelea Nels ape ree ests ie er ete tore ere ere oer oe | een ee a 
Cattlesmum bereersec asnat cece cc cranclepsiseecine ieee eee Ceeee ore Dane ee area eiven [eee no etns ne Seatac eee 
Barn built of ......, with ...... roof, in....... repairsmodded?s +5 se 0s gt | nes ee 
Hay and grainin above-mentioned barn.-.......... in orn sechavara mist aia ota alte & Scie eal | aetacera aes | SSeS oe oe | eee 
Silo with contents, diameter .... it. , height .. Bilbo 08 gine e FOP AG sis Seas eee ee ee 
Boel bal daswu cow cs des vs suid sliwoal ye aleu'aachucguls U0 SAVIN SOIR 5 ilies ie ee ep net 
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Further descriptions: ; SUMMARY. 
Dwelling—main anh; sc. wtb sys -hG- afte DOStS ser se hore built 
Ime re ; with wing or attachment .... ft. by . ft. posts, 
bwlitgin essere ; finished rooms ...., unfinished rooms . ; foundation Tnsur- ae 
ieee - number of chimneys ....; material ......, resting how? ...... ance by Class Initial 
are stove pipes properly insulated where passing through partitions or class, | 2nd rate. |premium. 
ceilings? ...... ; disposition of ashes ...... ; lighting system ...... ; 
occupied by ....... 
Granary—main part, ....ft. by .... ft., Gs este) Puilt ny sees : N 15 
with attachment or lean-to .... ft. by .... ft., .... ft. posts, used for |--------~~ 5 ee 
J ae eee ey me ai Ce ae 
attachment, or lean-to .... ft. by -... ft., .... ft. posts, used'for .). 25... 92242993 | is Rag ae 
ee a | 3 eae S| VET eee 
Iaasoconocc Pee MO} HEY ASE Sees Se 5)! 
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 rata share of all losses and legitimate expenses incurred by said 
company while said insurance remains in force. 
Signed: 
Dated this 
Address. 
I also affirm that the valuations, statements, and 
descriptions given in this application, are to the best of my knowledge and belief, correct. 
ear | 
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