SERFF Tracking #: CEMC State Tracking #: Company Tracking #: NC-HO PDF Free Download

SERFF Tracking #: CEMC-129028057 State Tracking #: Company Tracking #: NC-HO2013-2 State: North Carolina Filing Company: Central Mutual Insurance Company TOI/Sub-TOI: 04.0 Homeowners/04.0000 Homeowners Sub-TOI Combinations Product Name: Homeowners Program Project Name/Number: Equipment Breakdown Form/ General Information Project Name: Equipment Breakdown Form Project Number: Reference Organization: Reference Title: Filing Status Changed: 05/14/2013 State Status Changed: 05/14/2013 Created By: Beth Schlagbaum Corresponding Filing Tracking Number: State TOI: 04.0 Homeowners Status of Filing in Domicile: Pending Domicile Status Comments: Reference Number: Advisory Org. Circular: Deemer Date: Submitted By: Beth Schlagbaum State Sub-TOI: 04.0000 Homeowners Sub-TOI Combinations Filing Description: For new and renewal policies effective on and after September 1, 2013, we wish to update our Equipment Breakdown endorsement 7-1396 to a 07/13 edition to enhance the coverages included at no additional cost to the policyholder. Company and Contact Filing Contact Information Beth Schlagbaum, Rates & Forms Analyst bschlagbaum@central-insurance.com 800 South Washington St. PO Box 351 Van Wert, OH 45891 800-736-7000 [Phone] 2327 [Ext] 800-736-7026 [FAX] Filing Company Information Central Mutual Insurance Company PO Box 351 800 S. Washington St. Van Wert, OH 45891 (800) 736-7000 ext. [Phone] CoCode: 20230 Group Code: 36 Group Name: FEIN Number: 34-4202560 State of Domicile: Ohio Company Type: State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No PDF Pipeline for SERFF Tracking Number CEMC-129028057 Generated 05/14/2013 11:32 AM

* ON-DEMAND 1108 7-1396 7-1396 07/13 HOMEOWNERS EQUIPMENT BREAKDOWN COVERAGE AGREEMENT For an additional premium shown on the policy declarations, we cover direct loss to Covered Property caused by Equipment Breakdown. LIMIT OF LIABILITY The maximum amount payable for any one loss is $100,000. DEDUCTIBLE Equipment Breakdown is subject to a $500 per occurrence deductible. COVERED PROPERTY For the purposes of this endorsement, Covered Property means Dwelling, Other Structures, and Personal Property as defined in the HO0003, HO0004, HO0005, HE0007, or HO0006. PERILS COVERED Equipment Breakdown Equipment Breakdown as used herein means: a. Physical loss or damage both originating within: 1) Boilers, fired or unfired pressure vessels, vacuum vessels, and pressure piping, all normally subject to vacuum or internal pressure other than static pressure of contents, excluding: a. waste disposal piping; b. any piping forming part of a fire protective system; and c. any water piping other than: 1) boiler feed water piping between the feed pump and the boiler; 2) boiler condensate return piping; or 3) water piping forming part of a refrigerating or air conditioning system used for cooling, humidifying or space heating purposes 2) All mechanical, electrical, electronic or fiber optic equipment; and b. Caused by, resulting from, or consisting of: 1) Mechanical breakdown; 2) Electrical or electronic breakdown; or 3) Rupture, bursting, bulging, implosion, or steam explosion. However, Equipment Breakdown will not mean: Physical loss or damage caused by or resulting from any of the following; however if loss or damage not otherwise excluded results, then we will pay for such resulting damage: 1) Wear and Tear; 2) Rust or other corrosion, decay, deterioration, hidden or latent defect, mold or any other quality in property that causes it to damage or destroy itself; 3) Smog; 4) Settling, cracking, shrinking or expansion; 7-1396 07/13 Page 1 of 3

CONDITIONS 5) Nesting or infestation, or discharge or release of waste products or secretions, by insects, birds, rodents or other animals; 6) Any accident, loss, damage, cost, claim, or expense, whether preventative, remedial, or otherwise, directly or indirectly arising out of or relating to the recognition, interpretation, calculation, comparison, differentiation, sequencing, or processing of data by any computer system including any hardware, programs or software; 7) Scratching and marring; 8) Loss, damage, cost or expense directly caused by, contributed to by, resulting from or arising out of the following causes of loss: Fire, lightning, combustion explosion, windstorm or hail, weight of snow, ice or sleet, falling objects, smoke, aircraft or vehicles, riot or civil commotion, vandalism, sinkhole collapse, volcanic action, leakage from fire extinguishing equipment, water, water damage, earth movement and flood. 1. Equipment Breakdown does not extend beyond the insured s residence or other residences. 2. Green Environmental, Safety and Efficiency If Covered Property requires repair or replacement due to an Equipment Breakdown, we will pay; a. "Your" additional cost to repair or replace that property with equipment that is better for the environment, safer, or more efficient than the equipment being repaired or replaced. b. The additional reasonable and necessary fees incurred by the Insured for an accredited professional certified by a Green Authority to participate in the repair or replacement of physically damaged Covered Property as Green. c. The additional reasonable and necessary cost incurred by the Insured for certification or recertification of the repaired or replaced Covered Property as Green. d. The additional reasonable and necessary cost incurred by the Insured for Green in the removal, disposal or recycling of damaged Covered Property. e. The Loss of Use (if covered within the Policy to which this Equipment Breakdown Enhancement Endorsement Green Environmental and Efficiency Improvements is attached) loss during the additional time required for repair or replacement of Covered Property, consistent with Green, in the coverages above. However, "we" will not pay more than 150% of what the cost would have been to repair or replace such property with like kind and quality inclusive of fees, costs, and any loss of use loss incurred as stated above. The following Exclusions are added: Green Environmental, Safety and Efficiency Improvements does not cover any of the following: a. Any loss adjusted on any valuation basis other than a repair or replacement basis as per the Valuation section of this policy. b. Any loss covered under any other section of this policy. c. Any cost incurred due to any law or ordinance with which the Insured was legally obligated to comply prior to the time of the Equipment Breakdown. Green means products, materials, methods and processes certified by a Green Authority that conserve natural resources, reduce energy or water consumption, avoid toxic or other polluting emissions or otherwise minimize environmental impact. Green Authority means an authority on Green buildings, products, materials, methods or processes certified and accepted by Leadership in Energy and Environmental Design (LEED ), Green Building Initiative Green Globes, Energy Starr Rating System or any other recognized Green rating system. 7-1396 07/13 Page 2 of 3

These Conditions will be part of, and not an addition to, the limit of liability per loss or any other sublimits of this Policy. All other provisions of the HO0003, HO0004, HO0005, HE0007 or HO0006 apply. 7-1396 07/13 Page 3 of 3

May 14, 2013 HONORABLE WAYNE GOODWIN COMMISSIONER OF INSURANCE NORTH CAROLINA DEPARTMENT OF INSURANCE 1201 MAIL SERVICE CENTER RALEIGH NC 27699-1201 HOMEOWNERS PROGRAM EQUIPMENT BREAKDOWN FORM REVISION CENTRAL MUTUAL INSURANCE COMPANY FEIN #34-4202560 Company File #NC-HO2013-2 Dear Mr. Goodwin: The Central Mutual Insurance Company currently has on file with your Department our Equipment Breakdown Enhancement Endorsement for use with our Homeowners Program. For new and renewal policies effective on and after September 1, 2013, we wish to update our Equipment Breakdown endorsement 7-1396 to a 07/13 edition to enhance the coverages included at no additional cost to the policyholder. The following enhancements are included: 1) Increasing the coverage limit from $50,000 to $100,000 2) Increasing Expediting Expense from $2,500 per year to $10,000 per occurrence 3) Increasing Spoilage Coverage from $2,500 per year to $10,000 per occurrence 4) Increasing Pollutant Clean Up & Removal from $2,500 per year to $10,000 per occurrence 5) Adding Off-Premises Coverage with a $10,000 per occurrence limit. This will cover property temporarily located at a premises or location that is not a described location. 6) Combining the "Environmental, Safety, and Efficiency Improvements" coverage with the "Green Environmental and Efficiency Improvements". This coverage is now called "Green Environmental, Safety, and Efficiency Improvements". The limit is increased from 125% to 150% of what the cost would have been to repair or replace with like kind and quality. 7) Introducing a loss settlement provision that provides replacement cost loss settlement. Previously, loss settlement followed the Homeowners policy. A copy of the endorsement is attached for your review. We trust this will meet with your approval and look forward to receiving a favorable acknowledgement. Sincerely, Beth Schlagbaum Rates & Forms Analyst Phone: 1-800-736-7000 Ext. 2327 FAX: 1-800-736-7026 E-mail: bschlagbaum@central-insurance.com

NORTH CAROLINA DEPARTMENT OF INSURANCE FORM(S) QUESTIONNAIRE (1) NAME OF FILING ORGANIZATION Central Mutual Insurance Company (2) FILER'S FILE # NC-HO2013-2 (3) PROGRAM TITLE Equipment Breakdown (4) LINE(S) OF INSURANCE Homeowners (5) HOW MANY NEW FORMS AND/OR REVISED FORMS ARE BEING FILED? * NEW *REVISED 1 *Attach forms index, including form numbers, edition dates and titles. (6) LIST ALL OLD FORM(S) BEING WITHDRAWN AND DEPARTMENT FILE NUMBER (7) EXPLAIN THE PURPOSE(S) OF THIS FILING. (ATTACH SEPARATE SHEET) (8) LIST THE STATES WHERE THIS FILING HAS BEEN MADE NC (9) HAS THIS FILING BEEN MADE IN YOUR DOMICILIARY STATE? YES NO IF FILED, WHAT ACTION DID YOUR DOMICILIARY STATE TAKE? (10) LIST THE STATES THAT HAVE APPROVED THIS FILING (11) LIST THE STATES THAT HAVE DISAPPROVED THIS FILING AND REASON(S) FOR DISAPPROVAL (ATTACH SEPARATE SHEET). FC-048 (02/06)

(12) ATTACH COPIES OF ALL REQUIRED MODIFICATIONS REFERRED TO IN (10) ABOVE (13) IF THE FILING IS SIMILAR OR IDENTICAL TO A FILING MADE WITH THE N.C. DEPARTMENT OF INSURANCE BY A LICENSED BUREAU OR LICENSED RATING ORGANIZATION, COMPLETE THE FOLLOWING: (A) NAME OF AFFILIATED BUREAU OR RATING ORGANIZATION (B) NAME OF BUREAU OR RATING ORGANIZATION PROGRAM (C) IDENTIFICATION NUMBER OF BUREAU OR RATING ORGANIZATION PROGRAM (D) ARE YOU A MEMBER ; SUBSCRIBER ; SERVICE PURCHASER (14) IF THE FILING IS SIMILAR OR IDENTICAL TO A FILING MADE WITH THE N.C. DEPARTMENT OF INSURANCE BY A LICENSED INSURANCE COMPANY IN NORTH CAROLINA, GIVE THE N.C. INSURANCE DEPARTMENT FILE NUMBER AND APPROVAL DATE FILE # APPROVAL DATE ON A SEPARATE SHEET, DESCRIBE THE DIFFERENCE(S), IF ANY, BETWEEN YOUR FORM(S) AND THOSE OF THE PREVIOUSLY APPROVED PROGRAM (15) COMPUTER PRINTED DECLARATIONS PAGES SHOULD BE COMPLETED IN "JOHN DOE" FASHION AND ATTACHED. (16) PROPOSED EFFECTIVE DATE AND RULE OF IMPLEMENTATION 9-01-2013 (17) IF FILING AN EXCLUSION, DOES THIS EXCLUSION HAVE ANY PREMIUM IMPACT? NO YES. IS THIS COVERED IN A COMPANION FILING? NO YES PROVIDE COMPANY/NCDOI FILE NO. FOR COMPANION FILING (18) I CERTIFY THAT THE INFORMATION CONTAINED IN THIS QUESTIONNAIRE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNATURE OF OFFICER OF THE COMPANY OR HEAD OF THE FILINGS DEPARTMENT FC-048 (02/06)

* ON-DEMAND 1108 7-1396 AGREEMENT HOMEOWNERS EQUIPMENT BREAKDOWN COVERAGE 7-1396 11/0807/13 For an additional premium shown on the policy declarations, we cover direct loss to Covered Property caused by Equipment Breakdown. LIMIT OF LIABILITY The maximum amount payable for any one loss is $50100,000. DEDUCTIBLE Equipment Breakdown is subject to a $500 per occurrence deductible. COVERED PROPERTY For the purposes of this endorsement, Covered Property means Dwelling, Other Structures, and Personal Property as defined in the HO0003, HO0004, HO0005, HE0007, or HO0006. PERILS COVERED Equipment Breakdown Equipment Breakdown as used herein means: a. Physical loss or damage both originating within: 1) Boilers, fired or unfired pressure vessels, vacuum vessels, and pressure piping, all normally subject to vacuum or internal pressure other than static pressure of contents, excluding: a. waste disposal piping; b. any piping forming part of a fire protective system; and c. any water piping other than: 1) boiler feed water piping between the feed pump and the boiler; 2) boiler condensate return piping; or 3) water piping forming part of a refrigerating or air conditioning system used for cooling, humidifying or space heating purposes 2) All mechanical, electrical, electronic or fiber optic equipment; and b. Caused by, resulting from, or consisting of: 1) Mechanical breakdown; 2) Electrical or electronic breakdown; or 3) Rupture, bursting, bulging, implosion, or steam explosion. However, Equipment Breakdown will not mean: Physical loss or damage caused by or resulting from any of the following; however if loss or damage not otherwise excluded results, then we will pay for such resulting damage: 1) Wear and Tear; 2) Rust or other corrosion, decay, deterioration, hidden or latent defect, mold or any other quality in property that causes it to damage or destroy itself; 3) Smog; 4) Settling, cracking, shrinking or expansion; 7-1396 07/13 11/08 Page 1 of 3

CONDITIONS 5) Nesting or infestation, or discharge or release of waste products or secretions, by insects, birds, rodents or other animals; 6) Any accident, loss, damage, cost, claim, or expense, whether preventative, remedial, or otherwise, directly or indirectly arising out of or relating to the recognition, interpretation, calculation, comparison, differentiation, sequencing, or processing of data by any computer system including any hardware, programs or software; 7) Scratching and marring; 8) Loss, damage, cost or expense directly caused by, contributed to by, resulting from or arising out of the following causes of loss: Fire, lightning, combustion explosion, windstorm or hail, weight of snow, ice or sleet, falling objects, smoke, aircraft or vehicles, riot or civil commotion, vandalism, sinkhole collapse, volcanic action, leakage from fire extinguishing equipment, water, water damage, earth movement and flood. 1. Equipment Breakdown does not extend beyond the insured s residence or other residences. 2. Green Environmental, Safety and Efficiency Improvements If Personal Property requires replacement due to an Equipment Breakdown, we will pay your additional cost to replace with equipment that is better for the environment, safer and more efficient than the equipment being replaced. However, we will not pay more than 125% of what the cost might have been to repair or replace with like kind and quality. This condition does not increase any of the applicable limits. This condition does not apply to any property to which Actual Cash Value applies. 3. Green Environmental and Efficiency Improvements If Covered Property requires repair or replacement due to an Equipment Breakdown, we will pay; a. a. The lesser of the reasonable and necessary "Your" additional cost incurred by the Insured to repair or replace physically damaged Covered Propertythat property with equipment of like kind and quality which qualifies as Green. Like kind and quality includes similar size and capacitythat is better for the environment, safer, or more efficient than the equipment being repaired or replaced. b. b. The additional reasonable and necessary fees incurred by the Insured for an accredited professional certified by a Green Authority to participate in the repair or replacement of physically damaged Covered Property as Green. c. The additional reasonable and necessary cost incurred by the Insured for certification or recertification of the repaired or replaced Covered Property as Green. d. The additional reasonable and necessary cost incurred by the Insured for Green in the removal, disposal or recycling of damaged Covered Property. e. The Loss of Use (if covered within the Policy to which this Homeowners Equipment Breakdown Coverage Enhancement Endorsement Green Environmental and Efficiency Improvements is attached) loss during the additional time required for repair or replacement of Covered Property, consistent with Green, in the coverages above. WeHowever, "we" will not pay more than a maximum limit150% of $3,000what the cost would have been to repair or replace such property with equipment of like kind and quality inclusive of fees, costs, and any loss of use loss incurred as stated above. The following Exclusions are added: Green Environmental, Safety and Efficiency Improvements does not cover any of the following: 7-1396 07/13 11/08 Page 21 of 3

a. Any loss adjusted on any valuation basis other than a repair or replacement basis as per the Valuation section of this policy. b. Any loss covered under any other section of this policy. c. Any cost incurred due to any law or ordinance with which the Insured was legally obligated to comply prior to the time of the Equipment Breakdown. Green means products, materials, methods and processes certified by a Green Authority that conserve natural resources, reduce energy or water consumption, avoid toxic or other polluting emissions or otherwise minimize environmental impact. Green Authority means an authority on Green buildings, products, materials, methods or processes certified and accepted by Leadership in Energy and Environmental Design (LEED ), Green Building Initiative Green Globes, Energy Starr Rating System or any other recognized Green rating system. These Conditions will be part of, and not an addition to, the limit of liability per loss or any other sublimits of this Policy. All other provisions of the H00003, H00004, H00005HO0003, HO0004, HO0005, HE0007 or H00006HO0006 apply. 7-1396 07/13 11/08 Page 31 of 3

SERFF Tracking #: CEMC State Tracking #: Company Tracking #: NC-HO2013-2