AGENCY NAIC CODE POLICY NUMBER APPLICANT …

Page 1 of 3 Attach to ACORD 140 EFFECTIVE DATENAIC CODECARRIERPOLICY NUMBERAPPLICANT / first named INSUREDAGENCYThe ACORD name and logo are registered marks of ACORDAGENCY CUSTOMER ID:SUPPLEMENT TO PROPERTY SECTIONBUSINESS INCOME / EXTRA EXPENSE / RENTAL VALUEDATE (MM/DD/YYYY)RENTAL VALUEEXTRA EXPENSEBUSINESS INCOMEW/O EXTRA EXPENSEBUSINESS INCOME /EXTRA EXPENSEPREMISES #:BUILDING #:BUSINESS INCOME /RENTAL VALUEPREMISES INFORMATIONOFF PREM POWERPOWERWATERCOMM (DESCR BELOW)LIMITMO PERIODEXT PERIODDAYSMAX PERIODORDINARY PAYROLLEXCLINCL90 DAYS180 DAYS$TYPE OF BUSINESSNON MFGMFGMINING% COINSPOWER / HEAT$DEDDAYSELEC MEDIADAYSORD OR LAWDAYSCIVIL AUTHLDR LOC (DESC BELOW)MFG LOCREC LOCCONT LOCCOINDEPEND PROPBROAD FORMLIMITED FORM%%%%%LIMIT LOSS PAYDAYS PERIOD RESTEXTRA EXPENSENAME(S) AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPSERV / INCOTHER ED$STUDENTS$TUITION FEESOTHER COVERAGES 2005-2014 ACORD CORPORATION. All rights 810 (2014/12)ACORD 810 (2014/12)Page 2 of 3 AGENCY CUSTOMER ID:RENTAL VALUEEXTRA EXPENSEBUSINESS INCOMEW/O EXTRA EXPENSEBUSINESS INCOME /EXTRA EXPENSEPREMISES #:BUILDING #:BUSINESS INCOME /RENTAL VALUEADDITIONAL PREMISES INFORMATIONOFF PREM POWERPOWERWATERCOMM (DESCR BELOW)LIMITMO PERIODEXT PERIODDAYSMAX PERIODORDINARY PAYROLLEXCLINCL90 DAYS180 DAYS$TYPE OF BUSINESSNON MFGMFGMINING% COINSPOWER/HEAT$DEDDAYSELEC MEDIADAYSORD OR LAWDAYSCIVIL AUTHLDR LOC (DESC BELOW)MFG LOCREC LOCCONT LOC

Page 1 of 3 Attach to ACORD 140 EFFECTIVE DATE CARRIER NAIC CODE POLICY NUMBER APPLICANT / FIRST NAMED INSURED AGENCY The ACORD name and logo are registered marks of ACORD

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