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*$$$$AMOUNTTYPE%% %%PERCENT$$$$DEDUCTIBLEAMOUNTLIMITINCLUD EDINCLUDEDINCLUDEDOPTIONREPL COST - CONTENTSREPL COST - DWELLINGREPL COST - FULL VALUECOVERAGE* Includes DWELLING , Other Structures, Personal Property, Loss of Use** Not Applicable in North CarolinaTYPE%%%ANNUALNAMEDTHEFTWIND / HAILBASEPREMIUM%DEDUCTIBLEPERCENTADDITIO NAL EXPENSERENTAL VALUEMEDICAL PAYMENTS EA PERPERSONAL LIABILITY EA OCCLOSS OF USEPERSONAL PROPERTYCOVERAGELIMITBLANKET *DWELLINGOTHER STRUCTURESPREMIUM$$$$$$$$$$$$$$$$$$COVER AGES / LIMITS OF LIABILITYPage 1 of 5 DATE OF BIRTHSOCIAL SECURITY #* This field may not

wind / hail base premium % deductible percent additional expense rental value medical payments ea per personal liability ea occ loss of use personal property coverage limit blanket * dwelling other structures premium $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ... residence based business supp windstorm loss mitigation.

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  Applications, Fire, Dwelling, Deductible, Hail, Windstorm, Dwelling fire application

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