PROPERTY SECTION DATE (MM/DD/YYYY)
DEDTYPEAMOUNTBLKT #TYPEAMOUNTBLKT #LIMIT: $REJECT COVERAGEACCEPT COVERAGEMINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV)TYPEDEDBLANKET SUMMARYREFERENCE / LOAN #:EVIDENCE:RANK:CERTIFICATENAME AND ADDRESSACORD 45 attached for additional namesADDITIONAL INTERESTITEM:CLASS:ITEMITEM DESCRIPTIONBUILDING:LOCATION:INTEREST IN ITEM NUMBERMORTGAGEELOSS PAYEEINTERESTPROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARKY / NSOLID FUELBOILERSECONDARY HEATIF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / NSOLID FUELBOILERPRIMARY HEATIF BOILER, IS INSURANCE PLACED ELSEWHERE?GONGLOCALSTATIONCODE NUMBERFIRE DISTRICT# OF OPEN SIDES ON STRUCTURE:VALU-ATIONRIGHT EXPOSURE & DISTANCELEFT EXPOSURE & DISTANCEREAR EXPOSURE & DISTANCEFRONT EXPOSURE & DISTANCEBREAKDOWN OR CONTAMINATIONSELLINGPRICEPOWER OUTAGELIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)OPTIONSREFRIG MAINTAGREEMENT(Y / N)$DEDUCTIBLE$LIMITDESCRIPTION OF PROPERTY COVEREDSPOILAGECOVERAGE(Y / N)ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONVALUE REPORTING INFORMATION - Attach acord 811BUSINESS INCOME / EXTRA EXPENSE - Attach acord 810ADDITIONAL INFORMATIONSUBJECT OF INSURANCEAMOUNTCOINS %CAUSES OF LOSSINFLATIONGUARD %FORMS AND CONDITIONS TO APPLYBLKT#CONSTRUCTION TYPED
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) MINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV) ACCEPT COVERAGE REJECT COVERAGE LIMIT: $
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