NAMED INSURED ( Note: ALL NAMED INSUREDS …

1 property APPLICATION Coastal Agents Alliance, LLC (A Division of Orchid Underwriters Agency, LLC) 8025 Black Horse Pike, Suite 350 West Atlantic City, New Jersey 08232 Carrier Lantana POLICY TERM Proposed Effective Date Expiration Date Description Producer Policy Number NAMED INSURED ( Note: ALL NAMED INSUREDS MUST BE LISTED ON THE DEED) Name DOB SS# Home Phone No. ( ) - Mailing Address City State Zip Email PHYSICAL ADDRESS Is the Physical Address the same as the mailing address?

2 If no, Physical Address of property to be INSURED , Street Address: Work Phone No. Best Place to contact you: City State Zip County RATING DATA What year was the home built? _____ What type of garage do you have? - None - Attached - Detached What type of shape is the roof? - Gable - Hip - Flat - Not Known Number of stories of the home? - One - Two - Three - Four or more Does the dwelling have any of the following Hurricane Protection on all windows and doors? - Permanently installed shutters - Hurricane Glass - Plywood - None Choose a Wind Deductible Percent of Coverage A: - 1% $0000 - 2% $0000 - 5% $0000 Deductible for all other covered perils: - $ 1, - $ 2, - $ 5, - $10, Type of residence?

3 - Single Family - Two Family - Three or More Family - Condo Unit Owners ELIGIBILITY Is the NAMED INSURED one of the following: - LLC - LLP - Corporate - Estate - Trust - None of the above Is any part of the home built over water? - Yes - No How will the property to be INSURED be occupied? - Mix of Owner and Tenant - 100% Owner Occupied - 100% Tenant Occupied How many rental properties do the NAMED INSUREDS own? - No rental properties - One rental property - Two rental properties - Three or more rental properties Is the roof over 20 years old?

4 - No - Yes Are their any pets in your home? - Snake - Ferret - Exotic Animal - Other Please list_____ - Dog (Include Breed of Dog) _____ - None of the above Has the dog bitten anyone? - Yes - No _____ Is this INSURED or home currently INSURED with QBE or Coastal Agents Alliance, LLC? - No - Yes _____ Is this a mobile or manufactured home whether on a stationary foundation or not? - No - Yes Do you own a pool? - No - Yes If yes: -Is access ladder removed, or f fence locked when pool is not in use for an above ground pool.

5 - Is pool enclosed by a fence at least 4 feet high for an in ground pool. Is there a diving board or slide? - No - Yes _____ What type of Electrical Wiring is in the home? - Other - Knob & Tube - Aluminum What type of Electrical Protection system is in the home? - Stab-loc circuit breakers - non-Stab-loc circuit breakers - Fuses Is the location to be INSURED under construction or renovation? - No - Yes What type of heating system do you have? - Electric - Natural Gas - Oil - Propane or LPG - Wood Stove - No Heating System Will there be any renovations or demolition at this location?

6 - No - Yes Any incident of bankruptcy filing, property foreclosure, credit card revocation in the last 3 years? - No - Yes Is there any business conducted in the home or on the property ? - No - Yes Does the INSURED own a trampoline? - No - Yes Has anyone residing in the home been convicted of arson? - No - Yes Does this location contain Polybutylene Piping of any kind? - No - Yes Do you rent to tenants under 25 years or younger or do you rent to college students? - No - Yes If rented, How long is the minimum rental period?

7 - Less than Weekly - Weekly - Monthly - Annual - Not Rented Has there been a lapse of Insurance? - No - Yes _____ Has the applicant been cancelled for non-payment of premium in the last 3 years? - No - Yes How many claims have been made during the last 5 years for the property to be INSURED ? - None - One - Two - Three or more Briefly describe the loss: _____ _____ Is this home for sale or going to be listed for sale during the next 12 months? - No - Yes _____ Is there any unrepaired damage on the home, this includes damage that would not be covered by this policy?

8 - No - Yes IMPORTANT NOTICE: Personal Information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to determine either your eligibility for insurance or the premium you will be charged.

9 We may use a third party in connection with the development of your score. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information will be issued with your policy. This notice is given in compliance with the Federal Credit Reporting Act. FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

10 I hereby declare to the best of my knowledge and belief that all of the foregoing statements are true and these statements are offered as an inducement to the Company to issue the policy for which I am applying. I understand this policy may be cancelled if this application contains any false statement, omission, or material misrepresentation that would have otherwise altered the company s evaluation of the NAMED INSURED . I understand that motor vehicle records may be verified. Applicant s Signature _____ Applicant s Name (Please Print)_____ Date _____/_____/_____ Producer s Name (Please print) _____ Producer License # _____ Producer s Signature _____ Date _____/_____/_____ ADDITIONAL INFORMATION COVERAGE LIMIT PREMIUM What is the property to be INSURED built with ?