MORSTAN GENERAL AGENCY, INC.

Transcription

1 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park Woodbridge, NJ (732) ext. Ext 5201 Fax: (516) Enclosed you will find an annual non-admitted Commercial Package quote for Arkab Residential Properties I LLC. The quote number is MCP017MD046 Version 4. Section I- Section II- Section III- Section IV- Section V- Details the premiums, taxes and fees associated with this account. In addition, it provides the Underwriting tes and covers any of the additional underwriting information that might be needed prior to binding or within 21 days of the inception date. Summarizes the locations, building information, property coverages, warranties, and the corresponding classifications with the exposures and rates. Provides the Liability Limits of Insurance Lists the required coverage forms, notices, endorsements and exclusions. Offers optional coverages that are available to the applicant but are not currently included in the quote. In addition we have included some materials that will assist in the evaluation of this offer of coverage. An Excess General Liability quote that provides higher limits of Liability. It is attached as a separate quote under #XSL017M84E2. This quote is optional and not required to be bound along with the primary quote. If coverage is desired, we would issue a separate policy. A pre-filled application that includes the information you have already provided. Endorsement TRIADN Policyholder Disclosure tice of Terrorism Insurance Coverage for your review. A Point of Sale piece that provides some claims scenarios this account may encounter and a coverage checklist that can be compared to the quotation of another carrier. For your convenience, an area on page 1 of the quote has been provided to record your requested effective date and which optional coverages you might want to include when you are ready to bind coverage. We invite you to contact us to discuss the benefits of any coverages, the costs associated or simply to provide feedback! We welcome the opportunity to talk with you about this quote. Thank you for the opportunity to quote this account! Sincerely, Adam Goldfarb MORSTAN GENERAL AGENCY, INC. (732) ext. Ext 5201 Cover letter

2 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park Woodbridge, NJ (732) ext. Ext 5201 Fax: (516) MCP017MD046 Version 4 Quote is valid until 5/22/2017 Please bind effective: Re: To: Arkab Residential Properties I LLC Confirm optional coverages: Do not include any optional coverages. Include the following optional coverages from Section VI (Taxes & Fees may apply to optional premium if purchased) Option 1 - (add: *$403.00) - Terrorism Coverage *See Terrorism Section for Exact Pricing and Terms Attn: From: Commission: % Adam Goldfarb agoldfarb@morstan.com / (732) ext. Ext 5201 Signature: I. PREMIUM AND UNDERWRITING NOTES/REQUIREMENTS COMMERCIAL PACKAGE POLICY INFORMATION Carrier: Mount Vernon Fire Insurance Company Status: n-admitted A.M. Best Rating: A++ (Superior) - X Term Quoted: Annual Minimum Earned Premium: 95% COVERAGE PART PREMIUM Commercial Property $6, Commercial General Liability $1, TOTAL PREMIUM DUE TO CARRIER $8, ADDITIONAL COSTS Wholesaler Broker Fee New Jersey Surplus Lines Tax (5.000%) $ TOTAL AMOUNT DUE The premium quoted was calculated based on information provided by you in your application for insurance. The premium quoted may be adjusted based on an audit of your books and records during and/or at the conclusion of the policy period to determine actual receipts, payroll and other factors used to calculate earned premium. Within 21 days of the inception date of coverage, this account will be subject to the following: Our completed & signed application; or Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 1 of 5

3 MCP017MD046 Version 4 A completed & signed ACORD application as long as all underwriting information needed has been provided to us; or A completed & signed application from another company as long as all underwriting information needed has been provided to us. Identification of the applicable NJ Surplus Lines Examining Office 14 digit transaction control number is required. Underwriting tes: Additional credit may be available if construction site perimeter is protected with a locked fence. Prior to Bind Requirements: this account is subject to the following: Coverage cannot be bound without the following information. We may modify the terms and/or premiums quoted or rescind this quote if the information provided below or on the completed application materially affects the rating or eligibility of the risk. Home Office review and approval of a Certificate of Insurance from the General Contractor confirming General Liability limits of at least $1,000,000 Per Occurrence and $2,000,000 General Aggregate that names the applicant (as well as any other Additional Insureds for this policy) as an Additional Insured on the General Contractor's policy. The questions listed are part of the application. Responses are not needed if the completed and signed application specified is submitted at the time of binding. "x" indicates Prior to Bind requirement for Coverage Part Liab = Liability; Prop = Property; Liq = Liquor; Cr = Crime; IM = Inland Marine; Liab Prop Eligibility Question (applies to all locations) Response x x Is the building currently damaged by fire or otherwise? x x Has construction work started, other than site preparation? x x Are there past, pending or planned foreclosures and/or bankruptcies or judgments for unpaid taxes against the named insured or any officer, partner, member or owner, individually within the last five years? Has Insurance coverage been cancelled or non-renewed in the past three years? (not applicable in MO) x Is there a swimming pool on premises? x Does the project involve the underpinning or shoring of adjacent buildings or structures? x Is the project expected to last beyond 12 months? x If applicant is owner of the property being renovated, is the building 100 percent vacant? x Does the General Contractor provide a certificate of insurance showing General Liability limits of at least $1m/$2m with the applicant listed as an additional insured? x Is this a tract housing project (five or more structures)? Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 2 of 5

4 MCP017MD046 Version 4 Liab Prop Eligibility Question (applies to all locations) Response x Is the building scheduled for demolition during the policy term (except incidental non-load bearing interior work)? x Are there any exterior operations over four stories or more than 50 feet from grade level? x Is any work being performed by the applicant, their employees or volunteers? x Will the applicant be conducting business operations prior to the completion of the project? x Are there any blasting operations? x Is there any construction, installation, renovation or removal of underground tanks (except residential fuel oil tanks)? x Is the applicant entering into a written contract with one general contractor? II. COVERED LOCATION(S) AND CORRESPONDING CLASSIFICATIONS Location #1-107 Park Ave, rth Plainfield, NJ Construction: Frame / Protection Class: 3 Property Coverage Perils: Special Excluding Sprinkler Leakage Coverage Limit Coinsurance Deductible Valuation Rate Premium Building $450,000 80% $1,000 Replacement Cost $3,708 Building Improvements $550, % $1,000 Replacement Cost $2,266 Equipment Breakdown Included $1, $397 Mechanical Breakdown,Electrical Arcing Loss or damage to hot water boilers & steam equipment Steam explosion of boilers, piping, engines & turbines $250,000 limit for Perishable Goods Spoilage $250,000 limit for Refrigeration Contamination Coverage provided by Equipment Breakdown Warranted Property Conditions Maintain heat at a level throughout building to prevent pipes from freezing [P-23] Premises Fully Secured and Locked When t in Use [P-21] structural work for the load bearing members of the building. [P-19] Property Coverage Premium for Location #1: $6,371 Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 3 of 5

5 MCP017MD046 Version 4 Liability Coverage Description Vacant Building - Construction & Premises Protective Product Additional Insured - Mortgagee, Assignee or Receiver Contractors - Subcontracted Work - in connection with Construction & Premises Protective Product Fire Class Basis Exposure Prod/CompOps All Other Prod/CompOps All Other Code Code Rate Rate Premium Premium Area 2,800 Excl Excl $121 Per 1,000 Area Flat Cost of the Project Flat 550,000 Per 1,000 Cost of the Project Excl Excl Incl Excl Excl $1,559 Liability Coverage Premium for Location #1: $1,680 III. LIABILITY LIMITS OF INSURANCE COMMERCIAL GENERAL LIABILITY Each Occurrence $1,000,000 Personal Injury and Advertising Injury $1,000,000 Medical Expense (Any One Person) $5,000 Damage To Premises Rented to You $100,000 Products/Completed Ops Aggregate Excluded General Aggregate $2,000,000 General Liability Deductible $0 Total for Location: $8,051 IV. REQUIRED FORMS & ENDORSEMENTS Common Endorsements 2110 (09/10) Service Of Suit Jacket (09/10) Commercial Insurance Policy Jacket IL0017 (11/98) Common Policy Conditions TRIADN (02/15) Policyholder Disclosure tice of Terrorism Insurance Coverage Property Endorsements CP 112 CP 141 CP 142 CP 224 CP 225 CP 226 (10/12) Equipment Breakdown Enhancement Endorsement CP0010 (06/07) Building And Personal Property Coverage Form (04/15) Actual Cash Value Definition CP0090 (07/88) Commercial Property Conditions (04/14) Protective Devices Or Services Provisions CP0450 (07/88) Vacancy Permit (02/11) Asbestos Material Exclusion CP1030 (06/07) Causes Of Loss - Special Form (02/11) Exclusion - Lead Contamination CP1032 (08/08) Water Exclusion Endorsement (02/11) Absolute Pollution Exclusion - Property CP1056 (06/07) Sprinkler Leakage Exclusion CP 227 (02/11) Mold, Fungus, Bacteria, Virus Or Organic Pathogen Exclusion IL0111 CP 228 (02/11) Amendment To Exclusion - Causes Of IL0935 Loss - Special Form CP 229 (02/11) Coverage Period Endorsement - Covered L-367B Property Under Renovation CP 230 (02/11) Building Renovation Warranty P 249 Endorsement CP 245 (09/15) Earth Movement Exclusion (11/03) New Jersey Changes (07/02) Exclusion Of Certain Computer-Related Losses (10/98) Minimum Earned Premium Endorsement (01/15) Exclusion of War, Military Action and Terrorism (Coverage for Certain Fire Losses) Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 4 of 5

6 MCP017MD046 Version 4 General Liability Endorsements CG0001 (12/07) Commercial General Liability Coverage L-500 Form CG0068 (05/09) Recording And Distribution Of Material Or Information In Violation Of Law Exclusion L-526 CG2018 (04/13) Additional Insured - Mortgagee, Assignee L-540 or Receiver CG2104 (11/85) Exclusion - Products-Completed L-549 Operations Hazard CG2107 (05/14) Exclusion - Access Or Disclosure Of L-571 Confidential Or Personal Information And Data-Related Liability - Limited Bodily Injury Exception t Included (02/11) Bodily Injury Exclusion - All Employees, Volunteer Workers, Temporary Workers, Casual Laborers, Contractors, and Subcontractors (01/15) Absolute War Or Terrorism Exclusion (11/09) Exclusion - Exterior Work Over 50 Feet (11/12) Absolute Professional Liability Exclusion (02/11) Exclusion - Exterior Finish Systems CG2136 (03/05) Exclusion - New Entities L-599 NJ (10/12) Absolute Exclusion for Pollution, Organic Pathogen, Silica and Asbestos-New Jersey CG2139 (10/93) Contractual Liability Limitation L-600 (08/05) Pre-Existing Or Progressive Damage Or Defect Exclusion CG2147 (12/07) Employment-Related Practices Exclusion L-610 (11/04) Expanded Definition Of Bodily Injury CG2294 (10/01) Excl - Damage To Work Performed By Subcontractors On Your Behalf L-625 IL0021 (09/08) Nuclear Energy Liability Exclusion L-685 Endorsement (02/11) Work Completed Or Premises Put To Use Exclusion (05/10) Premises Limitation Endorsement IL0141 (09/08) New Jersey Changes - Civil Union L-690 (02/11) Work Performed By The Insured Exclusion L-232s (09/05) Classification Limitation Endorsement L-783 (02/14) Amendment Of Liquor Liability Exclusion L-367B (02/11) Minimum Earned Premium Endorsement LLQ-100 (07/06) Amendatory Endorsement L-424 (05/10) Exclusion - Blasting LLQ-368 (08/10) Separation Of Insureds Clarification Endorsement V. OFFER OF OPTIONAL COVERAGE(S) Based on the information provided, the following additional coverages are available to this applicant but are not currently included in the quotation. The additional premium may be subject to taxes & fees. For a firm final amount please contact us and we will revise the quote. Coverage Additional Premium Option 1 Terrorism Coverage $ Important Information Terrorism coverage, per the Terrorism Risk Insurance Program Reauthorization Act of 2015, is available for an additional premium of 5.00% of the total policy premium. If not purchased, please provide the signed TRIADN Disclosure tice or add form NTE - tice of Terrorism Exclusion. When making your decision to purchase Terrorism Coverage, please be aware that coverage for "insured losses" as defined by the Act is subject to the coverage terms, conditions, amount, and limits in this policy applicable to losses arising from events other than acts of terrorism. The Terrorism premium shown above has been calculated as a percentage of the quoted coverages. If any coverages are added or removed at binding, the additional premium shown above is subject to change. This coverage cannot be added mid-term. Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 5 of 5

7 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park Woodbridge, NJ (732) ext. Ext 5201 Fax: (516) Enclosed you will find an annual admitted Excess General Liability Coverage for Arkab Residential Properties I LLC. The quote number is XSL017M84E2 Version 2. Section I- Section II- Section III- Section IV- Section V- Details the premiums, taxes and fees associated with this account. In addition, it provides the Underwriting tes and covers any of the additional underwriting information that might be needed prior to binding or within 21 days of the inception date. Schedule of Underlying Coverages Lists the required coverage forms, notices, endorsements and exclusions. Offers optional coverages that are available to the applicant but are not currently included in the quote. Provides the Direct Bill Payment Description. In addition we have included some materials that will assist in the evaluation of this offer of coverage. A pre-filled application that includes the information you have already provided. Endorsement TRIADN Policyholder Disclosure tice of Terrorism Insurance Coverage for your review. A Point of Sale piece that provides some claims scenarios this account may encounter and a coverage checklist that can be compared to the quotation of another carrier. The carrier will send the insured an invoice based on the terms reflected in this quote. Payment is due to the carrier. Payment options available to you are: 1. Send the invoice remittance slip with payment to the lockbox address on their invoice 2. Pay online at < 3. Pay by phone (automated system available 24/7) at The policyholder can register their policy at < By registering their policy, the insured will have access to additional information as well as the option to set-up recurring payments. Recurring payments are a great way to minimize the possibility of the insureds policy being cancelled or not renewed because payment was not received. We invite you to contact us to discuss the benefits of any coverages, the costs associated or simply to provide feedback! We welcome the opportunity to talk with you about this quote. Thank you for the opportunity to quote this account! Sincerely, Adam Goldfarb Cover letter

8 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park Woodbridge, NJ (732) ext. Ext 5201 Fax: (516) MORSTAN GENERAL AGENCY, INC. (732) ext. Ext 5201 Cover letter

9 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park Woodbridge, NJ (732) ext. Ext 5201 Fax: (516) XSL017M84E2 Version 2 Quote is valid until 5/22/2017 Please bind effective: Re: To: Attn: From: Arkab Residential Properties I LLC Commission: % Adam Goldfarb agoldfarb@morstan.com / (732) ext. Ext 5201 Confirm optional coverages: Do not include any optional coverages. Include the following optional coverages from Section IV (Taxes & Fees may apply to optional premium if purchased) Option 1 - Terrorism Coverage This policy is eligible to be Direct Billed. te: a $5.00 installment fee will apply to each installment after the first - please select one of the following: Direct Bill both this New Business and future Renewals (If checked - Select a Payment Plan): SINGLE PAYMENT TWO PAYMENTS - Premium must be over $400 THREE PAYMENTS - Premium must be over $675 See the last page of this quote for Payment Plan Descriptions Do not Direct Bill this New Business but do Direct Bill future Renewals Do not Direct Bill this policy NOTE: If the Direct Bill Option is selected, the Company will invoice the insured. Do not bill or collect the down payment. All taxes, surcharges and fees (except installment fees) will be billed in full with the first installment. Signature: I. PREMIUM AND UNDERWRITING NOTES/REQUIREMENTS EXCESS GENERAL LIABILITY COVERAGE POLICY INFORMATION Carrier: United States Liability Insurance Company Status: Admitted A.M. Best Rating: A++ (Superior) - X Term Quoted: Annual LIMIT OPTIONS PREMIUM TAXES FEES AMOUNT DUE $1,000,000 $400 (MP) $ $ $ $2,000,000 $800 (MP) $ $ $ $3,000,000 $1,200 (MP) $ $ $ $4,000,000 $1,600 (MP) $ $ $ $5,000,000 $2,000 (MP) $ $ $ ADDITIONAL COSTS Wholesaler Broker Fee $ Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 1 of 3

10 XSL017M84E2 Version 2 FREE AND DISCOUNTED BUSINESS SERVICES AVAILABLE TO USLI INSUREDS VISIT BIZRESOURCECENTER.COM FOR DETAILS Please note that we will not be able to bind coverage until we satisfy all Prior to Binding requirements.we have provided a pre-filled application that would assist in satisfying these requirements. Prior to binding, this account is subject to the following: Confirmation that all of the following are True: There are no past, pending or planned foreclosure and/or bankruptcy or judgment for unpaid taxes against the named insured or any officer, partner, member or owner, individually within the past five years The building is not currently damaged by fire or otherwise Within 21 days of the inception date of coverage, this account will be subject to the following: Our completed & signed application; or A completed & signed ACORD application as long as all underwriting information needed has been provided to us; or A completed & signed application from another company as long as all underwriting information needed has been provided to us. Underwriting tes: Please be advised, we have prepared this quote of higher limits of liability based on the information provided for a primary quote. It is valid only over the United States Liability Insurance Group quote provided, however we can consider adjusting it to be valid over other carriers. In addition, we can possibly include other lines of coverage in the underlying such as Automobile Liability and Employer's Liability. Please contact me if you wish to discuss further. II. SCHEDULE OF UNDERLYING COVERAGES Commercial General Liability Limits of Liability Carrier: Mount Vernon Fire Insurance Company Each Occurrence: $1,000,000 AM Best Rating: A++g III. REQUIRED FORMS & ENDORSEMENTS Products/Completed Operations Excluded Aggregate: General Aggregate: $2,000,000 Personal & Advertising Injury: $1,000,000 IUL100 (07/06) Expected or Intended Injury Exclusion NOTICE (02/17) Advisory tice to Policyholders UNMANNED AIRCRAFT XL IUL117 (09/10) Nuclear Energy Liability Exclusion (Broad Form) TRIADN (02/15) Policyholder Disclosure tice of Terrorism Insurance Coverage L-424 (05/10) Exclusion - Blasting XL101 (05/07) Automobile Exclusion L-532 (08/03) Exclusion - Construction Operations XL102 (04/07) Exclusion-Operations Covered By A Consolidated (Wrap-Up) Insurance Program L-540 (11/09) Exclusion - Exterior Work Over 50 Feet XL465 (12/16) Exclusion - Unmanned Aircraft L-549 (05/05) Absolute Professional Liability Exclusion XL542 (02/15) Exclusion Of War And Certified Acts Of Terrorism L-571 (08/04) Exclusion - Exterior Finish Systems XLP (07/05) Excess Liability Policy L-589 (01/06) Bodily Injury Exclusion - All Employees, XLP Jacket Volunteer Workers, Temporary Workers, Casual Laborers, Contractors, And Subcont (09/10) Excess Liability Policy Jacket Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 2 of 3

11 XSL017M84E2 Version 2 IV. OFFER OF OPTIONAL COVERAGE(S) Based on the information provided, the following additional coverages are available to this applicant but are not currently included in the quotation. The additional premium may be subject to taxes & fees. For a firm final amount please contact us and we will revise the quote. Coverage Rate Option 1 Terrorism Coverage See notes for rate information Important Information Terrorism coverage, per the Terrorism Risk Insurance Program Reauthorization Act of 2015, is available for an additional premium of $100 or % of the total premium for this risk, whichever is greater. If not purchased, please provide the signed TRIADN Disclosure tice or add form NTE tice of Terrorism Exclusion. When making your decision whether to purchase Terrorism Coverage, please be aware that coverage for "insured losses" as defined by the Act is subject to the coverage terms, conditions, amount and limits in this policy applicable to losses arising from events other than acts of terrorism. Coverage available under this offer is contingent on the underlying policies providing terrorism coverage and at the same limit as the Schedule of Underlying Coverages This coverage cannot be added mid-term. V. DIRECT BILL PAYMENT PLAN DESCRIPTIONS SINGLE PAYMENT TWO PAYMENTS THREE PAYMENTS One Year Payment Plan Descriptions: - The entire premium is invoiced immediately and is due 20 days after it is invoiced. - 50% of the premium is invoiced immediately and is due 20 days after it is invoiced; the balance is invoiced 60 days after inception. - 40% of the premium is invoiced immediately and is due 20 days after it is invoiced; 30% is invoiced 60 days after inception; the balance is invoiced 120 days after inception. An installment fee as noted on page 1 of this quote applies to each installment after the first. Please contact us with any questions regarding the terminology used or the coverages provided. **Read the quote carefully, it may not match the coverages requested** Page 3 of 3

12 MORSTAN GENERAL AGENCY, INC Route 9 rth, Suite 204, Aspen Corporate Park, Woodbridge, NJ Phone: (732) xext 5201 Fax: (516) Mount Vernon Fire Insurance Company Commercial Package Application MCP017MD046 Version 4 You or your agent provided the information used to complete the questions below. Please answer all remaining questions in the space provided. By signing this application you are warranting that all information on this application is true and correct. I. General Information Applicant's Name: Arkab Residential Properties I LLC Form Of Business: Individual Corporation Partnership LLC Other: Mailing Address: 107 Park Ave City: rth Plainfield State: NJ Zip: Phone Number: Web Address: Fax Number: Address: Inspection Contact: Coverage Desired: Monoline Liability Monoline Property Monoline Liquor Package Policy Term: 3 Months 6 Months 9 Months Annual Has coverage been cancelled or non-renewed in the last 3 years (not applicable in the state of MO)? If, provide complete details: What year did the business start? 2018 Loss Information for the past 3 years: ne or provide details below Please advise all entities requesting to be added as Additional Insured on this policy: t Applicable Complete Name Address Interest Description of Operations: Vacant bldg. under renovations Are there past, pending or planned foreclosures and/or bankruptcies or judgments for unpaid taxes against the named insured or any officer, partner, member or owner, individually within the last five years? Has Insurance coverage been cancelled or non-renewed in the past three years? (not applicable in MO) II. Locations of Coverage and Corresponding Classifications Location #1 Address City 107 Park Ave rth Plainfield Years At Current Location: 2/18/2018 State NJ Zip Page 1 of 4

13 Construction: Frame Protection Class: 3. of Stories: Year Built: 1960 Total Square Footage: 2,800 Years at this location: Roof Age: 7 Roof Type: Flat Shingle Wood Shake Metal Tile Slate Plumbing: PVC Copper Lead Iron Galvanized Other Updates: Plumbing: Electrical: Heating: Other Protective Devices: Cause of Loss: Functional & operational smoke detectors Burglar Alarm Fire Alarm Sprinkler System - Special Form Central Station Central Station % of the building Broad Form Basic Form Local Local Exclusions: Wind & Hail Sprinkler Leakage Theft Water Damage Deductible: $500 $1,000 $2,500 $5,000 Other Coverage Limit Additional Information Building $450,000 Co-Insurance: 80% % Valuation: Replacement Cost Actual Cash Value Building Improvements $550,000 Co-Insurance: 80% % Equipment Breakdown Valuation: Replacement Cost Actual Cash Value Included in Co-Insurance: 80% % Building and Personal Property Underwriting Information for Location 1 Classification Vacant Building - Construction & Premises Protective Product Additional Insured - Mortgagee, Assignee or Receiver Contractors - Subcontracted Work - in connection with Construction & Premises Protective Product Code. GL Class Code Premium Basis Exposure Area 2800 N/A Flat 1 Cost of the Project Applicable Sq. Ft. Is the building currently damaged by fire or otherwise? Is the building scheduled for demolition during or after the policy term (except incidental non-load bearing interior work)? Are there any structural (load bearing) renovations ongoing or planned during the policy term? Is the structure a mobile home? Has any tenant been evicted in the past 60 days or is any tenant in the process of being evicted? Is the building locked and secured from unauthorized entry? Has construction work started, other than site preparation? Is there any adding of stories to an existing structure? Is there a swimming pool on premises? Does the project involve the underpinning or shoring of adjacent buildings or structures? Is the project expected to last beyond 12 months? If applicant is owner of the property being renovated, is the building 100 percent vacant? Does the General Contractor provide a certificate of insurance showing General Liability limits of at least $1m/$2m with the applicant listed as an additional insured? Is this a tract housing project (five or more structures)? Is the building scheduled for demolition during the policy term (except incidental non-load bearing interior work)? 2/18/2018 Page 2 of 4

14 Is the applicant the owner of the building? Will this project site be protected by a fence when workers are not present? Will a watchman be on premises during non-working hours? What is the full mailing address of the Additional Insured? What is the name of the Additional Insured? III. Limits of Insurance COMMERCIAL GENERAL LIABILITY Each Occurrence $1,000,000 Personal Injury and Advertising Injury $1,000,000 Medical Expense (Any One Person) $5,000 Damage To Premises Rented to You $100,000 Products/Completed Ops Aggregate Excluded General Aggregate $2,000,000 General Liability Deductible $0 IV. Eligibility Criteria Classification Vacant Building - Construction & Premises Protective Product Liability Are there any exterior operations over four stories or more than 50 feet from grade level? Is any work being performed by the applicant, their employees or volunteers? Will the applicant be conducting business operations prior to the completion of the project? Are there any blasting operations? Is there any construction, installation, renovation or removal of underground tanks (except residential fuel oil tanks)? Classification Contractors - Subcontracted Work - in connection with Construction & Premises Protective Product Liability Name of General Contractor Is the applicant entering into a written contract with one general contractor? Does the General Contractor carry its own insurance with limits greater than $1,000,000 per occurrence and $2,000,000 General Aggregate? V. Additional Eligibility Information Does the Applicant engage in any operations or have any classifications on their premise(s) other than those listed in Item II Locations of Coverage and Corresponding Classifications? 2/18/2018 Page 3 of 4

15 New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim 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 may subject such person to criminal and/or civil penalties and other sanctions. Applicant's Warranty Statement: I warrant that the information provided in this Application, and any amendments or modifications to this Application are true and correct. I acknowledge that the information provided in this Application is material to acceptance of the risk and the issuance of the requested policy by Company. I agree that any claim, incident, occurrence, event or material change in the Applicant s operation taking place between the date this application was signed and the effective date of the insurance policy applied for which would render inaccurate, untrue or incomplete, any information provided in this Application, will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations and/or void any authorization or agreement to bind the insurance. Company may, but is not required, to make investigation of the information provided in this Application. A decision by the Company not to make or to limit such investigation does not constitute a waiver or estoppel of Company s rights. I acknowledge that this Application is deemed incorporated by reference in any policy issued by Company in reliance thereon whether or not the Application is attached to the policy. I acknowledge and agree that a breach of this WARRANTY STATEMENT is grounds for Company to declare void any policy or policies issued in reliance thereon and/or deny any claim(s) for coverage thereunder. Applicants Signature*: Brokers Signature: If your state requires that we have the name and address of your (insured s) authorized Agent or Broker. Name of Authorized Agent or Broker: Address: (Must be Owner, Officer or Partner) Title: (Required) Date: Date: (Required) SUBMITTING THIS APPLICATION DOES NOT BIND THE APPLICANT TO PURCHASE INSURANCE. ACCEPTANCE OF THIS APPLICATION DOES NOT BIND THE COMPANY TO ISSUE INSURANCE. 2/18/2018 Page 4 of 4

16 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk Insurance Act ("the Act"), as amended, you have a right to purchase insurance coverage for losses arising out of acts of terrorism. As defined in Section 102(1) of the Act: The term act of terrorism means any act or acts that are certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States, to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. You should know that any coverage for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States reimburses 85% through 2015; 84% beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2019 and 80% beginning on January 1, 2020, of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is provided below and does not include any charges for the portion of loss covered by the federal government under the Act. Coverage for "insured losses, as defined in the Act, is subject to the coverage terms, conditions, amounts and limits in this policy applicable to losses arising from events other than acts of terrorism. You should know that the Act, as amended, contains a $100 billion cap that limits U.S. Government reimbursement, as well as insurers' liability, for losses resulting from certified acts of terrorism when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. You should also know that, under federal law, you are not required to purchase coverage for losses caused by certified acts of terrorism. REJECTION OR SELECTION OF TERRORISM INSURANCE COVERAGE Please X one of the boxes below and return this notice to the Company. I decline to purchase Terrorism Coverage. I understand that I will have no coverage for losses arising from acts of Terrorism. I elect to purchase coverage for certified acts of Terrorism for a premium of $. te: if you do not respond to our offer and do not return this notice to the Company, you will have no Terrorism Coverage under this policy. Applicant Name (Print) Authorized Signature Named Insured Date TRIADN (02-15) Page 1 of 1

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