DWELLING FIRE APPLICATION DATE …

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 & VMMBROADSP

CIVIL UNION (if applicable) MARITAL STATUS * / ACORD 84 (2013/09) LOC #: PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)

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