III. Operations All operations and activities must be declared.

III. Operations All operations and activities must be declared. Receipts Members Only 1. Hunting: Big Game Upland Birds Waterfowl Other: $ 2. Clubhouse or Lodge (Complete Clubhouse and Lodge supplement.) $ 3. Sporting Clay / Trap / Skeet (Complete Archery & Rifle supplement.) $ 4. Archery Range (Complete Archery & Rifle supplement.) $ 5. Game Bird Sales to Others (preserve, restaurant, etc ) $ 6. Boats $ 7. Range (Rifle & Pistol)- indoors; outdoors (Complete Archery & Rifle supplement.) $ 8. Rental of Facilities to Others (Public)(Complete Private Parties, Conferences, Weddings supplement) $ 9. Liquor Sales (Complete Liquor Liability supplement.) $ 10. Private Parties / Social Activities (Complete Private Parties, Conferences, Weddings supplement) $ 11. Restaurant Sales $ 12. Fundraisers $ 13. Farming: Crops, Livestock $ 14. All Terrain Vehicles use: guided; unguided (Complete ATV supplement.) $ 15. Youth Camps (Complete Agriculture Camp supplement.) $ 16. Horse or Cattle Operation / Exposure $ 17. Guided Hunting or Fishing to Public for Fee (Complete O&G application.) $ 18. Other: $ 19. Other: $ 20. Total gross receipts for activities: $ 21. Are any activities offered for non-members? Yes No 22. a. Are members allowed to bring guests? Yes No b. Average number of guests / mth: c. Is there a guest fee? Yes No d. Receipts: $ 23. a. Does club contract out any activities? Yes No b. If yes, explain: Provide a certificate of insurance with admitted A rated carrier, with equal or greater general liability limits as applicant for contracted activities. 24. Total number of days operating per year: Date Open: to Date Close: 25. a. Total gross annual receipts for retail sales: $ None b. Describe items sold: c. Physical location address: d. Square footage of retail space: IV. Club Information 1. a. Does the club: Own or Lease a Clubhouse Lodge Bunkhouse Cabin Other: None b. Number of acres: Owned Leased/Private Land, for club operation. None 2. a. Does the club have a caretaker to: Look after premises Live on premises? Yes No b. If no, how often does applicant check premises: 3. Does club have a: Hot Tub Swimming Pool? Yes No If yes, please complete a Water Activity Supplement. 4. a. Is there any other business conducted on premises by the club? Yes No b. If yes, please give details: 5. Are any operations conducted outside the United States? Yes No 6. a. Does club provide any hunting weapons for non-members? Yes No b. If yes, indicate type and age of weapons: c. Does club provide: Gun Smithing Repair Services Ammunition Reloaded Ammunition? Yes No d. Does club sell Hunting Weapons Ammunition Reloaded Ammunition? Yes No e. Are loaded weapons allowed: Indoors While being transported? Yes No 7. a. Does the club Sell or Provide alcoholic beverages? Yes No b. Are club members allowed to bring their own alcohol? Yes No c. What type of alcohol: Beer, Wine, Liquor d. Is alcohol served or allowed at: Social activity; Before, During, or After fishing or activity with firearms? Yes No e. Is alcohol consumption allowed in the field? Yes No App Rod & Gun Club (Revision 02-01-06) Page 2 of 5

V. Camping Information 1. a. Are there: RV / Camping Trailer hook-ups or Camp Sites on the premises? Yes No b. If yes: Number of hook-ups: Number of camp sites: Are Sewers Water and Trash Disposals available to guest? Yes No Is the electrical and maintenance done by a licensed electrician? Yes No Any extension cords used for electric service? Yes No Does club provide any service or repair of engines? Yes No 2. Any sales of: Gasoline / Propane RV or Travel Storage RV or Travel Trailer Sales & Service Yes No VI. Hunting Questions 1. What type of game is being hunted? Bear, Deer, Elk, Hogs, Turkey, Upland Birds, Waterfowl, Other: 2. Is all game hunted considered fair chase? Yes No 3. What type of hunting weapons are used: Guns - Rifle Shotgun Pistol Black powder / Muzzle Loading Archery - Crossbow Recurve Compound Other - 4. a. Who is responsible for the layout of hunting lanes or designated areas for hunting for the club: b. What experience do they have: c. Does it meet the state regulatory agency? Yes No 5. a. Is all hunting done on foot? Yes No b. If no, explain: 6. a. What is the maximum number of members hunting at any one time: b. Does club keep a roster for daily hunting activities? Yes No 7. a. Are hunters back by dusk? Yes No b. If no, explain: 8. a. What do hunters use for transportation: Hunting Buggy (modified vehicle), All Terrain / Utility Vehicle, Other: None b. Are any of the above licensed for road use? Yes No c. Are vehicles owned by: Club Club Members? 9. a. Hunting stands used are: Manufactured Homemade and Portable Permanent None b. Type of hunting stand: Self Supporting Structure Ladder Climbing Tree Other: and Enclosed (4-sided) Open (no sides / 1 side) c. Who installs the hunting stands: Member Guest Other: d. How often are hunting stands checked for safety: Each use Weekly Seasonal Other: e. Are safety harnesses required? Yes No 10. Are hunters required to wear fluorescent orange per state regulatory agency guidelines? Yes No 11. a. How many hunting dogs are owned by: Club: Members: Non-Members/Guests: None b. Are all dogs required to have current vaccinations? Yes No c. Is club: Selling, Breeding, or Training dogs for other than club use? Yes No 12. a. Does club use any boats for hunting operations? Yes No b. What methods are used for stabilizing boats while shooting: 13. Is the general public allowed to hunt on premises? Yes No VII. Fishing Questions 1. Type of fishing: Casting, Fly, Float, Ice, Other: 2. What percentage of fishing is: Wading- % Shoreline- % Boat- % 3. Does the club provide fishing equipment to non-members? Yes No 4. Does the club provide training/instruction? Yes No 5. Is rental or use of boats available to non-members? (If yes, complete Boat questions, Section VIII.) Yes No 6. a. Where is fishing conducted: Lake, Pond, Stream, River, Other: b. Name of river: 7. What is the minimum age required for fishing: 8. Are children always accompanied by an adult? Yes No 9. What is the duration of the fishing activity: Hourly, Half Day, Full Day, Overnight App Rod & Gun Club (Revision 02-01-06) Page 3 of 5

Ice Fishing Questions - 1. How does club determine if the ice is safe to use: 2. Who drills the holes in the ice? Club, Non-Member, Other: 3. Are ice conditions posted? Yes No 4. Are vehicles permitted on the ice? Yes No 5. Are ice huts used to fish in? Yes No 6. a. Does the club provide equipment to non-members? Yes No b. Describe equipment: 7. Indicate how the club and non-members get to the fishing location: Dog Sled Rides, Snowmobiles, ATV / Utility Vehicle, Other: VIII. Boat Questions 1. a. On what bodies of water does use take place: Rivers Lakes/Ponds Ocean Bay/Inlets b. If rivers, what classes are navigated: Class I Class II Class III Class IV Class V or higher 2. Maximum passenger capacity of each boat: 3. Are boats used for: Hunting Fishing Boat Rental Other : ( Complete Boat supplement.) 4. Are boats owned/leased by: Club or Individual Members? Yes No 5. Are non-members allowed to operate boats? Yes No 6. Are coast guard approved Personal Floatation Devices: Required and / or Provided? Yes No 7. Type & Number of boats used: Jon Boat:, Drift / Float Boat:, Row Boat:, Other: 8. Describe boats including type, length and horse power: IX. All Terrain Vehicles/Golf Carts/Snowmobiles Must complete an additional supplement. 1. Are club-owned All Terrain Vehicles / Golf Carts / Snowmobiles used for: Transporting Guests Tours /Sightseeing Game Retrieval Feeding of Animals Hunting Other: 2. a. Does club offer the use of D.O.T. helmets for All Terrain Vehicle and Snowmobile use? Yes No b. If yes, list all activities where the club offers the use of helmets: c. List all activities where the club requires helmets: d. What is the minimum age allowed to use an All Terrain Vehicle / Golf Cart / Snowmobile? years old 3. Are any vehicles ever loaned or given to club members for non-club activities? Yes No 4. a. Are non-members allowed to drive/ride club-owned: All Terrain Vehicles (including mules & gators), Snowmobiles, Golf Carts, Mopeds, None? b. What is the minimum age of rider/driver? years old 5. a. Who is responsible for maintenance of All Terrain Vehicles / Golf Carts / Snowmobiles: b. Does the club have a schedule and daily pre-use inspection log for all motorized vehicles? Yes No If yes, provide a sample copy. 6. Are members guests allowed to bring their own All Terrain Vehicle, Snowmobile, Golf Cart, Moped? Yes No 7. a. Number of: 4 or more wheels- personal use: club use: Golf Cart - personal use: club use: 3-wheel - personal use: club use: Other: - personal use: club use: b. Please provide vehicle: make, age and model: Note: No liability coverage for individually owned vehicles or non-club activities. App Rod & Gun Club (Revision 02-01-06) Page 4 of 5

X. Safety Information 1. Does the applicant require guests to complete a form with health and medical information prior to activities? Yes No 2. Does the applicant pre-screen guests and determine their ability prior to taking part in activities? Yes No 3. List reasons why the applicant would decline a person from taking part in a trip (i.e. health, age, weight, alcohol, general, pregnancy): 4. Does the club have a written: safety procedures manual, evacuation emergency plan given to all members? Yes No (Please provide a copy.) 5. Are all state safety regulations and rules followed and enforced? Yes No 6. Is a waiver/release of liability signed by non-members for all activities (including parent/legal guardian of minor)? Yes No (Provide a copy.) 7. Are waivers kept available on premises or archived for a minimum of 5 years? Yes No 8. Are all employees 18 years or older? No Employees Yes No 9. Which of the following safety items are taken on each activity? 50 Buoyant Rope, First Aid Kit, Flares, 2-way Radios, Mobile Phones, Snake Bite Kit, Heart Defibrillator, GPS 10. Are club-owned member-owned weapons/ammunition stored on premises? Yes No If yes, provide details: 11. a. Is property fenced? Yes No b. Is property posted? Yes No FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. In the District of Columbia, Louisiana, Maine, Tennessee and Virginia, insurance benefits may also be denied. I hereby certify that to the best of my knowledge and belief the information provided is true and correct and that no information which would materially affect this insurance has been withheld. Applicant s Signature Date Agent s Signature (if applicable) Date How did you hear about Markel: Magazine Ad Referral Convention Web Site Other Describe: Thank you for choosing Markel, The Insurance Company With Horse Sense App Rod & Gun Club (Revision 02-01-06) Page 5 of 5