DWELLING FIRE APPLICATION DATE …

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CIVIL UNION (if applicable)MARITAL STATUS * / acord 84 (2013/09)LOC #:PAYMENT PLAN (Attach acord 610, Premium Payment Supplement, if additional information is required)FINANCE COMPANYY / NPREMIUM FINANCED?MORTGAGEEINSUREDPAYORPRE-AUTHOR IZED DRAFT/CHECK (PAC)PAYROLL DEDUCTIONEFTCREDIT CARDCHECKCASHPAYMENT METHODMONTHLYBI-MONTHLYQUARTERLYSEMI-ANN UALANNUALFULL PAYPAYMENT PLANMAIL POLICY TO:AGENTINSUREDAGENCY BILLDIRECT BILL - ACCTDIRECT BILL - POLICYBILLINGBILLING ACCOUNT #:EST TOTAL PREMIUM:DEPOSIT AMOUNT:$$FORM NAMEFORMS AND ENDORSEMENTS ( acord 829, Forms and Endorsements Schedule, may be attached if more space is required)LOC #FORM NUMBEREDITION DATECOPYRIGHT OWNER CODESUSTAINEDACTUAL LOSS* Named Storm Percentage Deductible in North Carolina$%$%DEDUCTIBLES$%INCLUDEDSUSTAIN EDACTUAL LOSSTOTAL LOCATION PREMIUM$FIREFIRE & ECFIRE, EC & VMMBROADSPECIAL$$$% MAXHURRICANE**HURRICANE*$$$$AMOUNTTYPE%% %%PERCENT$$$$DEDUCTIBLEAMOUNTLIMITINCLUD EDINCLUDEDINCLUDEDOPTIONREPL COST - CONTENTSREPL COST - DWELLINGREPL COST - FULL VALUECOVERAGE* Includes DWELLING , Other Structures, Personal Property, Loss of Use** Not Applicable in North CarolinaTYPE%%%ANNUALNAMEDTHEFTWIND / HAILBASEPREMIUM%DEDUCTIBLEPERCENTADDITIO NAL EXPENSERENTAL VALUEMEDICAL

acord 84 (2013/09) explain all "yes" responses unless stated otherwise y / n 1.any other insurance with this company? (list policy numbers) line of business policy number line of business policy number

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