Location: Inside City Limits Outside City Limit Unprotected Name of Fire District Fire District#

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1 ENDORSEMENT FOR POLICY CHANGE INDEPENDENT MUTUAL FIRE INSURANCE COMPANY 4 NORTH PARK DR #402 HUNT VALLEY, MD Policy # Effective Date Of Change Agency #. (Must be the date Endorsement For Policy Change is completed) Requested Change: Change in Coverage Add/Delete Policy Endorsement (Burglary may NOT be added using this form) Address Change Change Name Add/Delete Additional Named Insured Lost Policy Application Add Delete Policy Assignment Section 1. Complete areas to be changed Change Coverage From $ Note: Enter New Coverage amount-do Not enter New Premium Amount here. To $ Change Burglary Limit Of Liability From $ To $ Emergency Expense Benefit Add Remove Endorsement Premium Jewelry, Firearms and Furs Benefit Add Remove Endorsement Premium Personal Liability Add Remove Endorsement Premium Refrigerated Food Spoilage Add Remove Endorsement Premium TOTAL NEW PREMIUM $ (Include base premium, ALL riders/endorsements and applicable taxes) AGENT NOTE: When adding Emergency Expense Benefit or Jewelry, Firearms and Furs, endorsement must be for the same amount as the base coverage/limit Of Liability. See Manual For Underwriting Rules and Rates for details. Section 2. Complete areas to be changed New Residence Code (After Change) Phone Number: Insured Address Change (May NOT be a seasonal or part-time residence. Named Insured must reside at Insured Address) Street Address City State Zip Describe Risk: Single Family Multi-Family (Duplex, Townhouse, Rowhouse, Apartment Building) Mobile Home KENTUCKY ONLY: Municipality/County 3 digit code NORTH CAROLINA ONLY Territory Protection Residence Construction Type Fire Hydrant Fire Station Code Class Code 5 Road Miles or Less Frame 1000 Ft. or less Over 6 Road Miles Masonry Over 1000 Ft. Between 5 & 6 Road Miles Location: Inside City Limits Outside City Limit Unprotected Name of Fire District Fire District# LOUSIANA ONLY Construction Type Frame Masonry Mobile Home Location: Inside City Limits Residence Code Name of Fire District Outside City Limits Section 3 Complete areas to be changed Name Change Phone Number: Change Insured Name From To S.S # Reason for Name Change Does Named Insured reside at Insured Address? Yes No Underwriting Note: The Named Insured must reside at the Insured Address on a permanent, full time basis. DO NOT complete Endorsement For Policy Change if Named Insured does not reside at Insured Address. Add/Remove Additional Named Insured: Add Remove Name Add Remove Name I certify that the above policy has been lost or destroyed and request a certificate of the policy Add Delete Policy Assignment Date Named Insured Signature X Additional or Other Insured Signature X Form FRE-003 (Rev. 05/2018) Completion of Policy Assignment must include properly signed and executed Notice Of Benefit Assignment. Attach all applicable forms assigning policy benefits. Agents Signature X

2 EXECUTIVE 4 North Park Drive Suite 402 Hunt Valley, MD 21030

4 EXECUTIV 4 NORTH PARK DRIVE SUITE 402 HUNT VALLEY, MD 21030

6 INDEPENDENT MUTUAL FIRE INSURANCE COMPANY 4 North Park Dr., Suite 402, Hunt Valley, MD Refrigerated Food Spoilage Endorsement This endorsement forms a part of the policy issued by Independent Mutual Fire Insurance Company. This endorsement is effective on the date set forth on the Declaration Page. For an additional premium as stated on the Declaration Page, we will provide coverage for loss due to spoilage of perishable foods. The food must be owned by an insured and kept in a refrigerator or freezer. The loss must be the result of electrical power interruption. Coverage is subject to the following conditions and limitations: 1. Loss of electrical power must; a) Be caused by the failure of any generating or transmitting equipment; b) Originate away from the Insured Location; c) Be from a peril named in the policy; d) Be wide spread and must have impacted more than the Insured Location; and e) Be for a continuous 24-hour period. The Benefit Amount shown on the Declaration Page is the maximum aggregate amount we will pay during any calendar year for food spoilage. When a covered loss occurs, we will pay the value of the spoiled perishable food up to the maximum Benefit Amount. We will not apply any deductible. At our option, we may accept photographic evidence of the perishable food spoilage loss. The Named Insured may be required to submit proof of the duration of the power interruption. Nothing herein contained shall be held to alter, vary, waive, modify, or extend any terms, conditions, or limitations of this policy or endorsements other than as stated above. Form #FRE-071(05/2018)

7 Independent Mutual Fire Insurance Company 4 North Park Dr. Suite 402 Hunt Valley, MD ADDITIONAL INSURED-LESSORS OF INSURED LOCATION Forms a part of Policy Number: This endorsement changes the coverage in your policy. Please read your policy and this Endorsement carefully. Endorsement Effective Date: Personal Liability Coverage Schedule 1. Designation of Insured Location Address (Property Leased To You): City State Zip 2. Name of Person or Organization Additional Insured- Lessor Name Address City State Zip A. For purposes of this endorsement, the definition of an insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to: 1. Liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule. 2. The extent permitted by law. 3. A contract or agreement, which requires the additional insured in the schedule to be shown: and 4. A contract or agreement, which is currently in effect, or becomes effective during the term of this policy; and is executed prior to any bodily injury or property damage ; and 5. Only for damages arising from your sole negligence, or the sole negligence of a family member. B. If coverage provided to the additional insured shown in the schedule is required by a contract or agreement, the insurance afforded will not be broader than that which you are required by the contract or agreement to provide. C. If coverage provided to the additional insured shown in the schedule is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. D. This endorsement does not increase the applicable Limits of Insurance shown in the Declarations. E. This Additional Insured endorsement is subject to the following exclusions: We will not pay for bodily injury or property damage : 1. Arising out of any occurrence, which takes place after you cease to be a tenant at that Insured Location 2. Arising out of any structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. Secretary President FRE-064 (Rev. 04/2018)

U NDERWRITERS R ATING B OARD

U NDERWRITERS R ATING B OARD P.O. BOX 13-059 ALBANY, NEW YORK 12212 PROGRAM BULLETIN # DWG-8 NOVEMBER 1, 1996 All rates, rules and forms promulgated by the Underwriters Rating Board are advisory in nature