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DWELLING FIRE APPLICATION DATE (MM/DD/YYYY)

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*$$$$AMOUNTTYPE%% %%PERCENT$$$$DEDUCTIBLEAMOUNTLIMITINCLUD EDINCLUDEDINCLUDEDOPTIONREPL COST - CONTENTSREPL COST - DWELLINGREPL COST - FULL VALUECOVERAGE* Includes DWELLING , Other Structures, Personal Property, Loss of Use** Not Applicable in North CarolinaTYPE%%%ANNUALNAMEDTHEFTWIND / HAILBASEPREMIUM%DEDUCTIBLEPERCENTADDITIO NAL EXPENSERENTAL VALUEMEDICAL PAYMENTS EA PERPERSONAL LIABILITY EA OCCLOSS OF USEPERSONAL PROPERTYCOVERAGELIMITBLANKET *DWELLINGOTHER STRUCTURESPREMIUM$$$$$$$$$$$$$$$

payroll deduction eft credit card check cash payment method monthly bi-monthly quarterly semi-annual annual full pay payment plan mail policy to: agent insured agency bill direct bill - acct direct bill - policy billing billing account #: deposit amount: est total premium:$ form name

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ACORD 0080 2013-09 - hpiainfo.com

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