or in Cellar. 
; while therein 
aile therein. 
. while therein. 
urn So. 1 
hed attached, 
On._ 
On. 
On. ; .roof..-..Barn Wo. 31 
[Material.] [Material.] ! 
...ft. x.ft., built in 18_) with Shed at-[ 
tached and including foundation. J 
On_____while therein. 
. Granary) 
[Material.] 
[Material.] 
ft. x.ft., built in i8_ 
On Corn Crib. 
On Grain therein. 
On... 
On .. 
On Grain in Stacks o 
On Hay in Stacks, c 
described (Hay c 
l cultivated field only, on Farm herein 
i marsh land not insured). 
; $ioo on any one animal, while in Barn or on Farm, and against Lightning while on or off premises, in use 
r pp 8 animal, while in Bam or on Farm, and against Lightning while on or off premises. 
.on Sheep on Farm herein described. Total Amount, $. 
.feet 
.Painted 18_ 
No. Sec.No. Twp.._..No. Range. 
Village of.....Lot...Block__:. 
5. Title—Have you fee simple title ?..If not, what kind of a title 
have you?......... 
6. Incumbrance—Is the property incumbered?...If so, what 
amount? $ .When due?..... 
Have there been any proceedings for foreclosure?..... 
7. ©tiler Insurance—Is there any other insurance?.Amount, $. 
If other insurance, give written form of policy. 
Cash Value—of land and buildings, $ .No. of acres?. 
How long have you owned the premises ?_____ 
liOSS by Fire —Have you ever had a loss by fire?.If so, state 
particulars on back hereof. 
Incendiarism—Have you any fears of incendiarism ?..... 
Barn— Condition?. Granary —Condition?.:.i., 
Is it occupied for private Barn only ?_ 
Distance from occupied Dwelling?.feet. 
my act, and the statements are warranted to be a correct description 
me or by my authority, and will be assumed 
d of all incumbrances. 
)nt and also Diagram on back of my Application. 
-Appt. 
ssSbSjjom jo Juiujt 
