AGENCY CUSTOMER ID: LOC #: RESIDENTIAL SECTION NAMED INSURED BROAD SPECIAL HOUSEKEEPING COND EXCELLENT CENTRAL DIRECT AVERAGE LOCAL DOOR LOCK

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Charla Bradley
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RESIDENTIAL SECTION DATE (MM/DD/YYYY) AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC INSURANCE REQUESTED HOMEOWNERS ENTER FORM NUMBER OR CHECK BOX FORM #: FIRE RATING / UNDERWRITING CONSTRUCTION

1 RESIDENTIAL SECTION DATE (MM/DD/YYYY) AGENCY NAMED INSURED POLICY NUMBER CARRIER NAIC INSURANCE REQUESTED HOMEOWNERS ENTER FORM NUMBER OR CHECK BOX FORM #: FIRE RATING / UNDERWRITING CONSTRUCTION TYPE COURSE OF CONSTRUCTION MASONRY VENEER FIRE RESISTIVE FRAME MASONRY MFG HOME STEEL BUILDERS RISK RENOVATION RECONSTRUCTION USAGE TYPE PRIMARY POURED CONCRETE LOG SECONDARY SEASONAL FARM SIDING ALUMINUM SIDING STUCCO OCCUPANCY VINYL SIDING / PLASTIC OWNER CEDAR, WOOD, SHINGLE TENANT EIFSCB (on cinder block) UNOCCUPIED EIFSS (on studs) VACANT DWELLING FIRE FIRE & EC FIRE, EC & VMM HOUSEKEEPING COND DISTANCE TO TIDAL WATER PURCHASE PRICE PURCHASE DATE WIRING COPPER ALUMINUM Miles KNOB & TUBE LAST INSPECTED DATE Feet MOBILE HOME BROAD SPECIAL PAYOR: APPLICANT PROTECTION DEVICE TYPE SYSTEM SMOKE TEMP BURGLAR CENTRAL DIRECT LOCAL DOOR LOCK DEADBOLT SPRING FIRE EXTINGUISHER (): FIRE DISTRICT NAME ELECTRICAL SYSTEMS CIRCUIT BREAKERS FUSES NUMBER OF AMPS SPRINKLER PARTIAL FULL PRIMARY HEAT SECONDARY HEAT MORTGAGEE DISTANCE TO FIRE HYDRANT DATE AGENT LAST INSPECTED PROPERTY FIRE STATION # FIRE DIVISIONS # UNITS FIRE DIV ITORY PERS LIAB PROT CLASS FIRE DIST DATE HEATING SYSTEM LAST SERVICED: MI FIRE PREM GROUP EC PREM GROUP FIRE/ EC RATE YEAR EIFS INSTALLED: SECURITY VISIBLE FROM ROAD VISIBLE TO NEIGHBORS OCCUPIED DAILY HOMEOWNER / DWELLING FIRE RATING / UNDERWRITING YEAR BUILT # ROOMS RESIDENCE TYPE DWELLING LOCATION RATING RENOVATIONS PART COMP YEAR MARKET VALUE REPLACEMENT COST # APARTMENTS # FAMILIES DWELLING APARTMENT CONDOMINIUM TOWNHOUSE ROWHOUSE IN CITY S IN FIRE DISTRICT IN PROT SUBURB WIND CLASS CLASS SPECIFIC FOUNDATION OPEN WIRING PLUMBING HEATING ROOFING EXTERIOR PAINT LIVING AREA # HOUSEHOLD RESIDENTS CO-OP RESISTIVE CLOSED PLUMBING CONDITION MOBILE HOME SEMI-RESISTIVE BASEMENT AREA # WEEKS RENTED SWIMMING POOL WINDSTORM GARAGE AREA TAX ABOVE GROUND STORM SHUTTERS A B IN GROUND HURRICANE RESISTIVE GLASS ANY KNOWN LEAKS? () BREEZEWAY AREA BLDG GRADE APPROVED FENCE FUEL STORAGE TANK LOCATION ROOF CONDITION DIVING BOARD INDOORS ABOVE GROUND MASONRY FLOOR FIREPLACES (Enter #) INSPECTED (): SLIDE INDOORS ABOVE GROUND NO MASONRY FLOOR CHIMNEYS HEARTHS RATING CREDITS LIGHTNING PROTECTION OUTDOORS ABOVE GROUND OUTDOORS BELOW GROUND PRE-FAB NON-SMOKER OFF PREMISE THE EXCL FUEL LINE LOCATION ROOF MATERIAL WOOD STOVE INSERT MANNED SECURITY UNDER GROUND THROUGH FOUNDATION REMARKS Page 1 of ACORD CORPORATION. All rights reserved. Attach to ACORD 88 The ACORD name and logo are registered marks of ACORD

2 MOBILE HOME RATING / UNDERWRITING NEW () ID NUMBER TIE DOWN PERMANENT CONNECTION TO COOKING LOCATION FULL COVERAGES / S OF LIABILITY COVERAGES DWELLING OTHER STRUCTURES PERSONAL PROPERTY LOSS OF USE BLANKET ( Includes Dwelling, Other Structures, Personal Property, Loss of Use) RENTAL VALUE (Dwelling Fire Only) ADDITIONAL EXPENSE (Dwelling Fire Only) PERSONAL LIABILITY EA OCC MEDICAL PAYMENTS EA PER OPTIONAL COVERAGES - ENDORSEMENTS COVERAGE TYPE ADDITIONAL PREMISES LIABILITY EXTENSION ADDITIONAL RESIDENCE RENTED TO OTHERS BUILDERS RISK ONLY THE OF BUILDING MATERIALS COLLAPSE DUE TO HYDRO-STATIC PRESSURE BUILDING ORDINANCE OR LAW COVERAGE S # PREMISES: COVERAGE INFORMATION # FAMILIES: # FAMILIES: UCTIBLES BASE WIND / HAIL THE NAMED HURRICANE* ANNUAL HURRICANE* MED PAY (): MED PAY (): MED PAY (): # FAMILIES: MED PAY (): * Not Applicable in North Carolina AGG TYPE FORM NUMBER AMOUNT FORM DATE BUSINESS PROPERTY AT HOME BUS PROP AWAY FROM HOME EARTHQUAKE YEAR CHASSIS ONLY OVERTOP ONLY DEBRIS REMOVAL RETROFIT TYPE: MASONRY VENEER: EMPLOYERS LIABILITY # OF EMPLOYEES: FIRE DEPARTMENT SERVICE CHARGE FLOOD BLDG CONTENTS FUNGUS AND MOLD MAKE: MODEL: ELECTRICITY WATER SEWER # PREMISES: EXCL LIABILITY EXCL PROP DAMAGE END MIDDLE LENGTH WIDTH FOUNDATION CONSTRUCTION CONTINUOUS MASONRY POST & PIER REBUILD PROPERTY LIABILITY # GOLF CARTS: GOLF CARTS - LIABILITY GOLF CARTS - PHYSICAL DAMAGE IDENTITY FRAUD EXPENSE COV INCIDENTAL FARMING PERS LIAB MEDICAL PAYMENTS (): DOUBLEWIDE (): SKIRTED (): # OF BEDROOMS MOBILE HOME PARK NAME DATE PARK ESTABLISHED # OF PERMANENT SPACES IN PARK CONSECUTIVE MONTHS OCCUPIED EACH YEAR: PERCENT LIABILITY - ELECTRONIC APPARATUS IN AND OUT OF VEHICLE LIABILITY - ELECTRONIC APPARATUS IN VEHICLE Page 2 of 5

3 OPTIONAL COVERAGES - ENDORSEMENTS (continued) COVERAGE TYPE LIABILITY - GUNS LIABILITY - MONEY LIABILITY - SECURITIES LIABILITY - SILVERWARE MINE SUBSIDENCE OFFICE, PROFESSIONAL PRIVATE SCHOOL, STUDIO - RESIDENCE PREMISES OTHER STRUCTURES - INDIVIDUAL STRUCTURE REQUIRES INCR CONTENTS INCR CONT NOT REQUIRED OT. STRUCTS COVERAGE INFORMATION STRUCT DESC: MED PAY () : FORM NUMBER FORM DATE STRUCT TYPE BUS/STRUCT DESC PLANTS, SHRUBS & TREES REFRIGERATED FOOD PRODUCTS REPLACEMENT COST - FULL VALUE REPLACEMENT COST - DWELLING REPLACEMENT COST - CONTENTS MAX SINK HOLE COLLAPSE UNIT-OWNERS ADDITIONS & ALTERATIONS SPECIAL COVERAGE UNSCHEDULED JEWELRY, WATCHES, FURS WATER BACKUP OF SEWERS & DRAINS AGG WATERCRA LIABILITY WINDSTORM EXCLUSION YES WORKERS COMPENSATION - FULL TIME INSERVANT WORKERS COMPENSATION - INCIDENTAL WORKERS COMPENSATION - PART TIME OUTSERVANT # OF EMPLOYEES: # OF EMPLOYEES: # OF EMPLOYEES: CONST MATERIAL: PROP DESC: INFLATION GUARD INCREASE LOSS ASSESSMENT WATERCRA PHYSICAL DAMAGE COVERAGE DESCRIPTION 1 2 TYPE: COVERAGE DESCRIPTION 1 2 TYPE: COVERAGE DESCRIPTION 1 2 TYPE: COVERAGE DESCRIPTION 1 2 TYPE: Page 3 of 5

4 GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES ANY BUSINESS CONDUCTED ON PREMISES? FARMING DAY CARE # OF CHILDREN: TELECOMMUTER HOME OFFICE/BUSINESS ANY RESIDENCE EMPLOYEES? # FULL TIME: # PART TIME: ANY FLOODING, BRUSH, FOREST FIRE OR LANDSLIDE HAZARD? 4. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES? ANIMAL TYPE BREED BITE HISTORY () 5. IS PROPERTY SITUATED ON MORE THAN ONE ACRE? 6. # OF ACRES: LAND USED FOR: ANY UNCORRECTED FIRE OR BUILDING VIOLATIONS? 7. IS THE DWELLING/MOBILE HOME FOR SALE? 8. IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY? 9. IS THERE A TRAMPOLINE ON THE PREMISES? SAFETY NET (): 10. WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? ORIGINAL OCCUPANCY: 11. ANY LEAD PAINT? 1 IF A FUEL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (If "YES", provide the name of the insurance company, the applicable limit and the cleanup sublimit) INSURANCE COMPANY: : 13. IS THE RESIDENCE IN A GATED COMMUNITY? NAME OF COMMUNITY: CLEANUP/SUB: 14. IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR? START DATE COMPLETION DATE INT EXT ADDITION (sq. ft.) ADD LEVEL (sq. ft.) ANY STRUCTURAL CHANGES () MATERIALS UNATTACHED (/EXCLU) HOUSE OCCUPIED DURING RENOVATION () COST OF PROJECT 15. IS THERE AN APPROVED CARBON MONOXIDE ALARM IN OPERATING CONDITION WITHIN THE MANDATED NUMBER OF FEET OF EVERY ROOM USED FOR SLEEPING PURPOSES? (IL - 15 ) GENERAL INFORMATION - RENTERS AND CONDOS ONLY EXPLAIN ALL "NO" RESPONSES 1. IS THERE A MANAGER ON THE PREMISES? MANAGER'S NAME: PHONE (A/C,No): IS THERE A SECURITY ATTENDANT? 3. IS THE BUILDING ENTRANCE LOCKED? Page 4 of 5

5 GENERAL INFORMATION - MOBILE HOME EXPLAIN ALL "YES" RESPONSES 1. DOES MOBILE HOME PARK HAVE A RESIDENT MANAGER? MANAGER'S NAME: PHONE (A/C,No): DOES MOBILE HOME PARK HAVE ED ACCESS? 3. DOES MOBILE HOME PARK HAVE SUBDIVISIONS? 4. ARE ROADS UNPAVED IN THE MOBILE HOME PARK? REMARKS ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND CIVIL PENALTIES. Page 5 of 5

DIRECTIONS: 1. Fill in the application by filling in the blue fields on all pages.

DIRECTIONS: 1. Fill in the application by filling in the blue fields on all pages. 1. 2. Please Complete fill in the all application enrollment the fields with form (all the pages) (all correct pages)