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6 Leatherstocking Cooperative Insurance Company Policy Application, Dwelling Fire & Seasonal Residence Dwelling Fire Dwelling Fire Mobile Home Seasonal Residence Seasonal Residence Mobile Home Proposed Term Effective Proposed Term Expiration Policy Period: 1 year, 12:01 AM Standard Time, 12:01 AM Standard Time LCIC- DF/SR Ed. 09/2017 P.O. Box 630, 4313 County Highway 11 Cooperstown, NY Phone: Fax: Replaces # Quote # Quoted Premium: $ Please complete an application for each additional location. Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different): Location Address: County: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Additional Interest: Mortgagee Additional Insured Other: Name: Address: Loan Number: Interest: Escrow Billed? Yes No Rating Information: Peril Coverage: Basic Form FL-1 with EC with VMM Broad Form FL-2 Special Form FL-3 Building Loss Settlement: Replacement Cost Actual Cash Value Deductible: Building Construction: Frame Masonry Mobile Home Is replacement cost on contents requested (ML-55)? Yes No (underwriting approval required) Additional Coverage s Requested: Coverages: Coverage A Residence Coverage B Related Private Structures Coverage C Personal Property Coverage D Additional Living Expense and Loss of Rents Coverage L Liability (each occurrence) Coverage M Medical Payments to Others (each person) Coverage M Medical Payments to Others (each occurrence) Barns and/or Incidental Farming Exposure: Is there any farming and/or farm animals on the premises? Yes No Acres - Number & Use: Farm Animals - Number & Description: All Barns - Number & Description: Type 1: Pole Type Construction Use: Size: X Limit: $ Heat: Yes No Hay: Yes No Type 2: All Other Use: Size: X Limit: $ Heat: Yes No Hay: Yes No *ML-56 Related Private Structures Exclusion Available Page 1 of 2

7 Mobile Home: Year: Dimensions of Mobile Home: x Is the mobile home fully skirted? Yes No Does the mobile home have a peaked roof? Yes No Is the mobile home on a permanent foundation (a slab does not constitute a permanent foundation)? Yes No Underwriting Questionnaire: Has agent seen the risk? Yes No Replacement Cost of Dwelling: (replacement cost estimator required on RC policies) Is this a new purchase? Yes No If yes, purchase price? $ If no, how long has insured owned this property? Year of Construction: Protective Devices: Battery Smoke Alarm Exterior and/or Interior Hardwired Smoke Alarm Low Temp Alarm (proof required) Sprinklered (proof required) Fire and/or Police Department Alarm (proof required) Central Station Burglary and/or Fire Alarm (proof required) None Other Is the risk currently occupied? Yes No If no, explain: Is the property currently for sale or going to be held for sale in the near future? Yes No If yes, list sale price: $ Number of Families and/or Units: # Is the property under renovation? Yes No If yes, provide estimated completion date: Is risk owner occupied? Yes No Is this property a Town House or Row House? Yes No If yes, are there fire walls? Yes No Is there a central heating system? Yes No Is there an underground fuel tank? Yes No Is there an open foundation? Yes No Does the risk have a flat roof? Yes No Fire District: Miles to fire department: Feet from fire hydrant: Is the risk located more than 200 feet from a year round maintained road? Yes No Are there any wood stoves, wood furnaces, pellet stoves, fireplace inserts or any other type of solid fuel devices? Yes No If yes, Type: How many? # (solid fuel device questionnaire required) Is there a trampoline? Yes No (if yes, FL-52 Trampoline Exclusion required) Is there a swimming pool? Yes No If yes, Is it an inground pool? Yes No Does it have a diving board? Yes No Is it fenced? Yes No Any dogs at this location? Yes No (EX-1 Dog Exclusion available) If yes, How many? # Breed(s): Any biting history? Yes No Are there any short term rentals? Yes No If yes, for how long each year? Is there any business conducted on the premises? Yes No If yes, explain: Do you own any saddle animals and/or recreational vehicles or are there any other liability hazards? Yes No Are there any outbuildings (garage, shed, etc)? Yes No If yes, How many, Description & Use of each: Does the applicant have any prior or current policies with our company? Yes No If yes, policy number(s): Additional Remarks: Underwriting Questions: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE - A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE - 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Insured Signature: Agent Signature: Page 2 of 2

8 Leatherstocking Cooperative Insurance Company Policy Application, Homeowners & Mobile Homeowners Homeowners Tenant Homeowners Mobile Homeowners Tenant Mobile Homeowners Proposed Term Effective Proposed Term Expiration Policy Period: 1 year LCIC- HO/MHO Ed. 09/2017 P.O. Box 630, 4313 County Highway 11 Cooperstown, NY Phone: Fax: Replaces # Quote # Quoted Premium: $, 12:01 AM Standard Time, 12:01 AM Standard Time Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different): Location Address (if different): County: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Additional Interest: Mortgagee Additional Insured Other: Name: Address: Loan Number: Interest: Escrow Billed? Yes No Rating Information: Peril Coverage: Basic Form ML-1 Broad Form ML-2 Special Form ML-3 Contents Broad ML-4 Superior Form ML-5 Building Loss Settlement: Replacement Cost Actual Cash Value Modified Replacement Cost (Homeowners only) Deductible: Building Construction: Frame Masonry Is replacement cost on contents requested (ML-55)? Yes No Additional Coverage s Requested: Coverages: Coverage A Residence Coverage B Related Private Structures Coverage C Personal Property Coverage D Additional Living Expense and Loss of Rents Coverage L Liability (each occurrence) Coverage M Medical Payments to Others (each person) Barns and/or Incidental Farming Exposure: Is there any farming and/or farm animals on the premises? Yes No Acres - Number & Use: Farm Animals - Number & Description: All Barns - Number & Description: Type 1: Pole Type Construction Use: Size: X Limit: $ Heat: Yes No Hay: Yes No Type 2: All Other Use: Size: X Limit: $ Heat: Yes No Hay: Yes No *ML-56 Related Private Structures Exclusion Available Page 1 of 2

9 Mobile Home: Year: Dimensions of Mobile Home: x Is the mobile home fully skirted? Yes No Does the mobile home have a peaked roof? Yes No Is the mobile home on a permanent foundation (a slab does not constitute a permanent foundation)? Yes No Underwriting Questionnaire: Has agent seen the risk? Yes No Replacement Cost of Dwelling: (replacement cost estimator required on RC policies) Is this a new purchase? Yes No If yes, purchase price? $ If no, how long has insured owned this property? Year of Construction: Protective Devices: Battery Smoke Alarm Hardwired Smoke Alarm Low Temp Alarm (proof required) Fire and/or Police Department Alarm (proof required) Central Station Burglary and/or Fire Alarm (proof required) Sprinklered (proof required) None Other Is the risk currently occupied? Yes No If no, explain: Is the property currently for sale or going to be held for sale in the near future? Yes No If yes, list sale price: $ Number of Families and/or Units: # Is risk owner occupied? Yes No Does the policyholder reside at this location year round? Yes No If no, explain: Is this property a Town House or Row House? Yes No If yes, are there fire walls? Yes No Is there a central heating system? Yes No Is there an underground fuel tank? Yes No Is there an open foundation (a foundation skirted with lattice would still be considered open foundation)? Yes No Does the risk have a flat roof? Yes No Fire District: Miles to fire department: Feet from fire hydrant: Are there any wood stoves, wood furnaces, pellet stoves, fireplace inserts or any other type of solid fuel devices? Yes No If yes, Type: How many? # (solid fuel device questionnaire required) Is there a trampoline? Yes No (if yes, FL-52 Trampoline Exclusion required) Is there a swimming pool? Yes No If yes, Is it an inground pool? Yes No Does it have a diving board? Yes No Is it fenced? Yes No Any dogs at this location? Yes No (EX-1 Dog Exclusion available) If yes, How many? # Breed(s): Any biting history? Yes No Is there any business conducted on the premises (including short term rentals)? Yes No If yes, explain (include annual receipts): If yes, is there an active business policy through the agency? Yes No Do you own any saddle animals and/or recreational vehicles or are there any other liability hazards? Yes No Are there any outbuildings (garage, shed, etc)? Yes No If tenant policy, is outbuilding available to the policyholder? Yes No If yes, How many, Description & Use of each: Does the applicant have any prior or current policies with our company? Yes No If yes, policy number(s): Additional Remarks: Underwriting Questions: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE - A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE - 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Insured Signature: Agent Signature: Page 2 of 2

10 LCIC- LLP Ed. 09/2017 Leatherstocking Cooperative Insurance Company Policy Application, Landlords Package Proposed Term Effective Proposed Term Expiration Policy Period: 1 year, 12:01 AM Standard Time, 12:01 AM Standard Time P.O. Box 630, 4313 County Highway 11 Cooperstown, NY Phone: Fax: Replaces # Quote # Quoted Premium: $ Please complete an application for each additional location. Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different): Location Address: County: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Additional Interest: Mortgagee Additional Insured Other: Name: Address: Loan Number: Interest: Escrow Billed? Yes No Rating Information: Peril Coverage: Basic Form FL-1with EC & VMM without VMM Broad Form FL-2 Special Form FL-3 Building Loss Settlement: Replacement Cost Actual Cash Value Deductible: (minimum $500 deductible on student housing) Is landlords contents coverage requested (FL-30)? Yes No If yes, limit: Is equipment breakdown requested (FL-345)? Yes No (minimum $25 per location) Is underground utility endorsement requested (FL-342)? Yes No ($17 for 1-2 family and $25 for 3-4 family) Additional Coverage s Requested: Coverages: Coverage A Residence Coverage B Related Private Structures Coverage D Additional Living Expense and Loss of Rents Coverage L Liability (each occurrence) Coverage M Medical Payments to Others (each person) Coverage M Medical Payments to Others (each occurrence) Barns and/or Incidental Farming Exposure: Is there any farming and/or farm animals on the premises? Yes No Acres - Number & Use: Farm Animals - Number & Description: All Barns - Number & Description: Type 1: Pole Type Construction Use: Size: X Limit: $ Heat: Yes No Hay: Yes No Type 2: All Other Use: Size: X Limit: $ Heat: Yes No Hay: Yes No *ML-56 Related Private Structures Exclusion Available Page 1 of 2

11 Student Housing: Do any students reside in the dwelling? Yes No (student housing supplement required) Total Number of Students: # Number of Students per Apartment: Apartment 1: # Apartment 2: # Apartment 3: # Apartment 4: # Are there any upper level porches or balconies? Yes No If yes, explain: Is risk affiliated with any student organization or club? Yes No Underwriting Questionnaire: Has agent seen the risk? Yes No Replacement Cost of Dwelling: (replacement cost estimator required on RC policies) What is the square footage of this property? Is this a new purchase? Yes No If yes, purchase price? Year of Construction: Building Improvements: Plumbing Year Wiring Year Roofing Year Heating Year Protective Devices: Battery Smoke Alarm Hardwired Smoke Alarm Low Temp Alarm (proof required) Fire and/or Police Department Alarm (proof required) Central Station Burglary and/or Fire Alarm (proof required) Sprinklered (proof required) None Other Is the risk currently occupied? Yes No If yes, % occupied or # of units occupied: If no, explain: Is the property currently for sale or going to be held for sale in the near future? Yes No If yes, list sale price: $ Number of Families and/or Units: # Is this property a Town House or Row House? Yes No If yes, are there fire walls? Yes No Is there a central heating system? Yes No Is there an underground fuel tank? Yes No Is there an open foundation? Yes No Does the risk have a flat roof? Yes No Fire District: Miles to fire department: Feet from fire hydrant: Are there any wood stoves, wood furnaces, pellet stoves, fireplace inserts or any other type of solid fuel devices? Yes No Is there a trampoline? Yes No (if yes, FL-52 Trampoline Exclusion required) Is there a swimming pool? Yes No If yes, who owns the pool? Any dogs at this location? Yes No (EX-1 Dog Exclusion available) If yes, How many? # Breed(s): Any biting history? Yes No Is there any business conducted on the premises (including short term rentals)? Yes No Do you own any saddle animals and/or recreational vehicles or are there any other liability hazards? Yes No Are there any outbuildings (garage, shed, etc)? Yes No If yes, How many, Description & Use of each: Does the applicant have any prior or current policies with our company? Yes No If yes, policy number(s): Additional Remarks: Underwriting Questions: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE - A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE - 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Insured Signature: Agent Signature: Page 2 of 2

12 LCIC- SMP/FL/CF Ed. 09/2017 P.O. Box 630, 4313 County Highway 11 Leatherstocking Cooperative Insurance Company Cooperstown, NY Phone: Fax: Policy Application, Commercial Policy Application ID: SMP Fire & Liability Fire Only Proposed Term Effective Proposed Term Expiration Policy Period: 1 year Quote Only Bound Application, 12:01 AM Standard Time, 12:01 AM Standard Time Please complete an application for each additional buildings and/or locations. Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different) & all owners names: Website: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Location Address: County: Insurable Interest: Named Insured s Interest in this property: Owner of Building Owner of Business in Building Other Type of Occupancy in Building: Owner Tenant Lessors Risk Only Is the named insured owner of this building? Yes No If yes, what name is the building deeded under? Description of Operations: Does the insured own and operate any business(es) in the building? Yes No If yes, what are the operations? If no, describe the operations & occupancies: Hours of operation: Percentage of alcohol? % Is there any commercial cooking in the building? Yes No If yes, type of cooking equipment (check all that apply): Grills Fryers Ovens Microwave Other Is there an ansul system? Yes No If yes, type: Wet Chemical Dry Powder Date of current inspection: Is there a maintenance contract? Yes No Is the ansul cleaned every 6 months? Yes No Does the insured own or operate any other business(es)? Yes No If yes, describe (operations & name operated in): If yes, does the insured carry professional or other general liability insurance? Yes No If yes, type: Any operations performed outside of New York State or in the following counties: Bronx, Kings, Nassau, New York, Putnam, Queens, Richmond, Rockland, Suffolk or Westchester? Yes No Does the named insured have direct sales outside of the United States or Canada? Yes No Does the named insured have any prior or current policies with our company? Yes No If yes, policy number(s): Has agent seen this risk? Yes No Additional Remarks: Page 1 of 4

13 Property Information: Total Building Square Footage: Number of Stories: # Square footage per occupancy: Is building vacant? Yes No Percentage occupied: % Multi-Occupancy? Yes No Roof: Flat Peaked Is there an open foundation? Yes No Is there an underground fuel tank? Yes No Building Construction: Frame Masonry Metal (will be rated as frame) Fire Resistive (needs approval) Year of Construction: Building Improvements: Plumbing Year Wiring Year Roofing Year Heating Year Distance to Hydrant: Feet Distance to Fire Station: Miles Fire District: Protective Devices: Battery Smoke Alarm Hardwired Smoke Alarm Central Station Alarm (proof required) Other: Sprinklered / % (building must be 100% sprinklered and in working order to apply credit, approval & proof required) Is this a seasonal risk? Yes No If yes, open/closed months: Is there a wood stove, wood furnace, pellet stove, fireplace insert or any other solid fuel devices? Yes No (if yes, supplemental questionnaire required) Building Coverage: Limit: _ Valuation: RC ACV Flat/ACV Form: SF-1(Basic) SF-2 (Broad) SF-3 (Special) SF -5 (Fire & EC Only) SF-6 (Fire Only) Is this a new purchase? Yes No If yes, purchase price? Business Property Coverage: Limit: _ Valuation: RC ACV Form: SF-1(Basic) SF-2 (Broad) SF-4 (Special) SF-4A (Special no theft) SF -5 (Fire & EC Only) SF-6 (Fire Only) Optional Property Endorsements: SF-43 Loss of Earnings: Limit: $ # of Months: 3 Months 4 Months 6 Months 12 Months SF-44 Extra Expense: Limit: $ SF-46 Loss of Rents: Limit: $ # of Months: 6 Months 12 Months SF-345 Equipment Breakdown requested? Yes No Extender Endorsement: SF-500 Business Extender EBE-LCIC Enhanced Business Extender SF-93 Food Spoilage: Limit: $ Deductible: $ Is there a Refrigeration Maintenance Agreement? Yes No SF-97 Off Premise Power: Limit: $ Deductible: $ SF-78A Glass Coverage: # of Panes: Linear Foot: Any lettering on the glass? Yes No Description: Water Damage, Sewers & Drains: ML-WD ($5000) SF-72A ($10,000) (cannot be combined) SF-47 Ordinance & Law Coverage: Demolition Cost: $ Increased Cost of Construction: $ Is there any knob and tube or fuse electric wiring? Yes No Is there asbestos siding? Yes No Is there any galvanized steel piping? Yes No Is there any asbestos wrapped piping? Yes No SF-133 Business Property While Away From Insured Premise: Limit: Other Property Endorsements Requested: Page 2 of 4

14 Inland Marine: Location Address: County: Radius of Operations: Type of Operation: Personal Use Business Use Please describe use of item(s): Where are the items/equipment being stored when not in use? Are the items/equipment leased or rented from others? Yes No If yes, explain: Are the items/equipment rented or loaned to others? Yes No If yes, explain: Limit: _ Liability Information: Any dog(s) on premise? Yes No If yes, how many and breed(s): Any biting history? Yes No Is there a trampoline on premise? Yes No (if yes, FL-52 Trampoline Exclusion required) Is there a swimming pool, pond or other water frontage exposure on premise? Yes No Are there any apartments in the building? Yes No If yes, how many? # Any student housing on premise? Yes No (if yes, supplemental questionnaire required) Any boarding housing or assisted living facilities on premise? Yes No Coverage L (Bodily Injury & Property Damage): Form: LS-1(OLT) LS-3(M&C) LS-5(BGL) Limits: $ (each occurrence)/ (each person) Coverage M (Medical Payments): Limits: $ (each person) / $ (each accident) Coverage N (Products/Completed Operations): Is Products/Completed Operations coverage requested? Yes No If yes, annual receipts? Optional Liability Endorsements: LS-49 Personal Injury requested? Yes No LS-48 Fire Damage Legal Liability: Limit: LS-50A Hired & Non Owned Auto: Limit: (supplemental questionnaire required) LS-44 Barber & Beauty Shop Liability: ( LS-76B Certain Skin Care Services Exclusion required on all beauty/barber shops) # of Employees: Full Time Stylists Part Time Stylists Barbers Manicurists LS-34 Liquor Legal: $100,000 $300,000 $1,000,000 (supplemental questionnaire required & LS-73 Assault & Battery Exclusion required on all risks serving alcohol) Other Liability Endorsements Requested: Page 3 of 4

15 Additional Interests: Please note: adding additional insured(s) requires pre-approval from underwriting and will be an additional premium. Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: Loan #: Escrow Billed? Yes No Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: Loan #: Escrow Billed? Yes No Named Insured History & Loss Information: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant s Signature: Producer s Signature: Page 4 of 4

16 LCIC- IM Ed. 09/2017 P.O. Box 630, 4313 County Highway 11 Leatherstocking Cooperative Insurance Company Cooperstown, NY Phone: Fax: Policy Application, Commercial Inland Marine Policy Proposed Term Effective Proposed Term Expiration Policy Period: 1 year, 12:01 AM Standard Time, 12:01 AM Standard Time Application ID: Quote Only Bound Application Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different) & all owners names: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Description of Operations: Location Address: County: Radius of Operations: Type of Operation: Personal Use Business Use Please describe use of item(s): Where are the items/equipment being stored when not in use? Are the items/equipment leased or rented from others? Yes No Are the items/equipment rented or loaned to others? Yes No Does the named insured have any prior or current policies with our company? Yes No If yes, policy number(s): Additional Remarks: MR-41 Mobile Farm Machinery Scheduled Equipment: Limit: _ Limit: _ Unscheduled Equipment: Limit: _ Page 1 of 3

17 MR-52 Miscellaneous Property Limit: _ MR-61A Computer Coverage Limit: _ MR-72 Contractors Equipment (use this classification for larger items such as backhoe, excavator, skid steer, large tractors, bulldozer etc) Limit: _ Limit: _ MR-79 Contractors Tools & Equipment (use this classification for small hand & power tools) Scheduled Equipment: Limit: _ Limit: _ Unscheduled Equipment: Limit: _ MR-91 Trailer Coverage Limit: _ Page 2 of 3

18 Other Classifications: Limit: _ Additional Interests: Please note: adding additional insured(s) requires pre-approval from underwriting. If additional space needed, please attach additional list. Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: For specific item: Loan #: Escrow Billed? Yes No Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: For specific item: Loan #: Escrow Billed? Yes No Named Insured History & Loss Information: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant s Signature: Producer s Signature: Page 3 of 3

19 LCIC- BOP Ed. 09/2017 P.O. Box 630, 4313 County Highway 11 Leatherstocking Cooperative Insurance Company Cooperstown, NY Phone: Fax: Policy Application, Businessowner s Policy Application ID: Standard BOP Deluxe BOP Proposed Term Effective Proposed Term Expiration Policy Period: 1 year Quote Only Bound Application, 12:01 AM Standard Time, 12:01 AM Standard Time Please complete an application for each additional buildings and/or locations. Named Insured: Mailing Address: Contact Name & Phone: Named Insured Address: Personal Name (if different) & all owners names: Website: Agency Code: Agency Name: Address: Phone: Submitted By: For Office Use Only: Payment: $ Check # Credit/Debit Electronic Check ACH Form Location Address: County: Insurable Interest: Named Insured s Interest in this property: Owner of Building Owner of Business in Building Other Type of Occupancy in Building: Owner Tenant Lessors Risk Only Is the named insured owner of this building? Yes No If yes, what name is the building deeded under? Description of Operations: Does the insured own and operate any business(es) in the building? Yes No If yes, what are the operations? If no, describe the operations & occupancies: Hours of operation: Percentage of alcohol? % Is there any commercial cooking in the building? Yes No If yes, type of cooking equipment (check all that apply): Grills Fryers Ovens Microwave Other Is there an ansul system? Yes No If yes, type: Wet Chemical Dry Powder Date of current inspection: Is there a maintenance contract? Yes No Is the ansul cleaned every 6 months? Yes No Does the insured own or operate any other business(es)? Yes No If yes, describe (operations & name operated in): If yes, does the insured carry professional or other general liability insurance? Yes No If yes, type: Any operations performed outside of New York State or in the following counties: Bronx, Kings, Nassau, New York, Putnam, Queens, Richmond, Rockland, Suffolk or Westchester? Yes No Does the named insured have direct sales outside of the United States or Canada? Yes No Does the named insured have any prior or current policies with our company? Yes No If yes, policy number(s): Has agent seen this risk? Yes No Additional Remarks: Page 1 of 4

20 Property Information: Total Building Square Footage: Number of Stories: # Square footage per occupancy: Is building vacant? Yes No Percentage occupied: % Multi-Occupancy? Yes No Roof: Flat Peaked Is there an open foundation? Yes No Is there an underground fuel tank? Yes No Building Construction: Frame Masonry Metal (will be rated as frame) Fire Resistive (needs approval) Year of Construction: Building Improvements: Plumbing Year Wiring Year Roofing Year Heating Year Distance to Hydrant: Feet Distance to Fire Station: Miles Fire District: Protective Devices: Battery Smoke Alarm Hardwired Smoke Alarm Central Station Alarm (proof required) Other: Sprinklered / % (building must be 100% sprinklered and in working order to apply credit, approval & proof required) Is this a seasonal risk? Yes No If yes, open/closed months: Is there a wood stove, wood furnace, pellet stove, fireplace insert or any other solid fuel devices? Yes No (if yes, supplemental questionnaire required) Standard BOP Deluxe BOP Business Owner s Coverage Included Included Additional Limits Requested Accounts Receivable $1,000 Additional Expense $1,000 $1,000 Fire Legal $50,000 $50,000 Personal Injury Included (optional) Loss Of Income 20% of Coverage A & 100% of Coverage B for 3 months 20% of Coverage A & 100% of Coverage B for 6 months Building Inflation 1% of increase each 3 months Employee Dishonesty $1,000 Exterior Signs $1,000 Money & Securities $1,000 Sprinkler Leakage 50% of Coverage B Valuable Papers and Records $1,000 While Away From Premises 15% Seasonal Variation 90 Days Building Coverage: Limit: _ Valuation: RC ACV Form: SF-1(Basic) SF-2 (Broad) SF-3 (Special) Is this a new purchase? Yes No If yes, purchase price? Business Property Coverage: Limit: _ Valuation: RC ACV Form: SF-1(Basic) SF-2 (Broad) SF-4 (Special) SF-4A (Special no theft) Optional Property Endorsements: SF-345 Equipment Breakdown requested (included)? Yes No Extender Endorsement: SF-500 Business Extender EBE-LCIC Enhanced Business Extender SF-93 Food Spoilage: Limit: $ Deductible: $ Is there a Refrigeration Maintenance Agreement? Yes No SF-97 Off Premise Power: Limit: $ Deductible: $ SF-78A Glass Coverage: # of Panes: Linear Foot: Any lettering on the glass? Yes No Description: Water Damage, Sewers & Drains: ML-WD ($5000) SF-72A ($10,000) (cannot be combined) SF-47 Ordinance & Law Coverage: Demolition Cost: $ Increased Cost of Construction: $ Is there any knob and tube or fuse electric wiring? Yes No Is there asbestos siding? Yes No Is there any galvanized steel piping? Yes No Is there any asbestos wrapped piping? Yes No Other Property Endorsements Requested: Page 2 of 4

21 Inland Marine: Location Address: County: Radius of Operations: Type of Operation: Personal Use Business Use Please describe use of item(s): Where are the items/equipment being stored when not in use? Are the items/equipment leased or rented from others? Yes No If yes, explain: Are the items/equipment rented or loaned to others? Yes No If yes, explain: Limit: _ Liability Information: Any dog(s) on premise? Yes No If yes, how many and breed(s): Any biting history? Yes No Is there a trampoline on premise? Yes No (if yes, FL-52 Trampoline Exclusion required) Is there a swimming pool, pond or other water frontage exposure on premise? Yes No Are there any apartments in the building? Yes No If yes, how many? # Any student housing on premise? Yes No (if yes, supplemental questionnaire required) Any boarding housing or assisted living facilities on premise? Yes No Coverage L (Bodily Injury & Property Damage): Form: LS-1(OLT) LS-5(BGL) LS-6(BGL-EC - approval required) Limits: $ (each occurrence)/ (each person) Coverage M (Medical Payments): Limits: $ (each person) / $ (each accident) Coverage N (Products/Completed Operations): Products/Completed Operations is automatically included, is this coverage requested? Yes No Optional Liability Endorsements: LS-49 Personal Injury requested? Yes No LS-50A Hired & Non Owned Auto: Limit: (supplemental questionnaire required) LS-44 Barber & Beauty Shop Liability: (LS-76B Certain Skin Care Services Exclusion required on all beauty/barber shops) # of Employees: Full Time Stylists Part Time Stylists Barbers Manicurists LS-34 Liquor Legal: $100,000 $300,000 $1,000,000 (supplemental questionnaire required & LS-73 Assault & Battery Exclusion required on all risks serving alcohol) Other Liability Endorsements Requested: Page 3 of 4

22 Additional Interests: Please note: adding additional insured(s) requires pre-approval from underwriting and will be an additional premium. Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: Loan #: Escrow Billed? Yes No Mortgagee Additional Insured Loss Payee Other: Name: Address: Interest: Loan #: Escrow Billed? Yes No Named Insured History & Loss Information: 1) During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other insurance related crime in connection with this or any other property? Yes No 2) Has any applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Yes No 3) Has any applicant been involved in any civil litigation in the past five years? Yes No 4) Has any coverage been declined, cancelled or non-renewed during the last five years? Yes No 5) Have there been any property or liability losses during the last 5 years, on any owned or previously owned risk in which you have or had an insured interest and/or any loss reported whether paid or not, resulting from past or current ownership? Yes No If yes, explain (list date, cause & amount): 6) Have there been any Property/Building code violations in the last three years? Yes No 7) Does the applicant have an insurable interest in the property and/or properties? Yes No If no, explain: BINDING STATEMENT: FAIR CREDIT REPORTING ACT NOTICE A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal or extension of the insurance for which this application is made. The applicant, upon request, will be informed whether or not a consumer report was requested and if report was requested, informed of the name and address of the consumer reporting agency that furnished the report. INSURANCE FRAUD WARNING NOTICE 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant s Signature: Producer s Signature: Page 4 of 4