PERSONAL INSURANCE APPLICATION DATE …

1 DATE (MM/DD/ yyyy )APPLICANT information SECTIONPERSONAL INSURANCE APPLICATIONRESIDENTIAL (89)INDICATE SECTIONS ATTACHEDPERSONAL INLAND MARINE (81) PERSONAL UMBRELLA (83)WATERCRAFT (82) PERSONAL AUTO (90) 2007 ACORD CORPORATION. All rights 1 of 4 The ACORD name and logo are registered marks of ACORDACORD 88 (2007/11)E-MAILADDRESS:AGENCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No):FAXINITIALS:COUNTYZIP + 4 STATECITYSTREETLOC #LOCATION SCHEDULE / GARAGING LOCATIONEXPIRATION DATEBI OR CSL LIMIT(S) IF APPLICABLELINE OF BUSINESSPRIOR COVERAGEPRIOR CARRIERPRIOR POLICY NUMBERPER PERSONPER ACCIDENT$$$$$$$$NO PRIOR COVERAGEPMAMTIMEPOLICY CHANGEPOLICY CHANGENEWRENEWSTATUS OF TRANSACTIONAPPLICANT INFORMATIONDATE OF BIRTHSOCIAL SECURITY #APPLICANT'S MAILING ADDRESSAPPLICANT'S NAME (First, Middle, Last)MARITAL STATUSPRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS:PREVIOUS ADDRESSYEARS AT PREVIOUS ADDRESS(if less than three years).

2 APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)APPLICANT'S EMPLOYER NAME AND ADDRESSBUSHOMECELLSECONDARYPHONE #PRIMARYBUSHOMECELLPHONE #CO-APPLICANT'S EMPLOYER NAME AND ADDRESSCO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)SECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:MARITAL STATUSCO-APPLICANT'S NAME (First, Middle, Last)CO-APPLICANT'S ADDRESSSOCIAL SECURITY #DATE OF BIRTHEFFECTIVE DATEBUSHOMECELLSECONDARYPHONE #PRIMARYBUSHOMECELLPHONE #DATE AT CURRENT RESIDENCEFACILITY CODEPLANNAIC CODECARRIEREXPIRATION DATEEFFECTIVE DATEPOLICY NUMBERNAMED INSUREDCAT #AMOUNT PAIDLINE OF BUSINESSLOSS HISTORYLOSS DATEDESCRIPTION OF LOSSENTERED BY$$$$$LOSS TYPE(A)GENT(C)OMPANYINDISPUTE(Y/N)Y/NANY LOSSES, WHETHER OR NOT PAID BY INSURANCE , DURINGTHE LAST YEARS, AT THIS OR AT ANY OTHER LOCATION?IF YES, INDICATE BELOWAPPLICANT'SINITIALS:$Page 2 of 4 INITIALS:EXPLAIN ALL "YES" RESPONSESY / NBODY APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGIES, MINI BIKES, ATVS, ETC), NOT SCHEDULED ON THIS POLICY?

3 DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREEOF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) INSURANCE BEEN TRANSFERRED WITHIN AGENCY? OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION , OWNED, OCCUPIED OR RENTED?GENERAL INFORMATIONLINE OF BUSINESSLINE OF BUSINESSPOLICY NUMBERPOLICY NUMBERANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS? (Not applicable in MO) APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS? ITEM NUMBER:BOAT:VEHICLE:BUILDING:LOCATION:TR USTEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONAL INSUREDINTEREST IN ITEM NUMBERCERTIFICATE REQUIREDREFERENCE #:NAME AND ADDRESSRANK:INTERESTITEM DESCRIPTION:ADDITIONAL INTERESTAGENCY CUSTOMER ID:ACORD 88 (2007/11)OTHERSCHEDULED ITEM NUMBER:BOAT:VEHICLE:BUILDING:LOCATION:TR USTEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONAL INSUREDINTEREST IN ITEM NUMBERCERTIFICATE REQUIREDREFERENCE #:NAME AND ADDRESSRANK:INTERESTITEM DESCRIPTION:OTHERSCHEDULED ITEM NUMBER:BOAT:VEHICLE:BUILDING:LOCATION:TR USTEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONAL INSUREDINTEREST IN ITEM NUMBERCERTIFICATE REQUIREDREFERENCE #:NAME AND ADDRESSRANK:INTERESTITEM DESCRIPTION:Page 3 of 4 INITIALS:$$DEPOSIT AMOUNT:EST TOTAL PREMIUM:BILLING ACCOUNT #:BILLINGDIRECT BILL - POLICYDIRECT BILL - ACCTAGENCY BILLINSUREDAGENTMAIL POLICY TO.

4 PAYMENT PLANPAYMENT PLANFULL PAYANNUALSEMI-ANNUALQUARTERLYBI-MONTHLYM ONTHLYPAYMENT METHODCASHCHECKCREDIT CARDEFTPAYROLL DEDUCTIONPRE-AUTHORIZED DRAFT/CHECK (PAC)PAYORINSUREDMORTGAGEEPREMIUM FINANCED ?Y/NFINANCE COMPANYFOR EFT, PAC OR CHECKBANK/ABA NUMBERACCOUNT NUMBERCHECK/REFERENCE NUMBERDAY OF MONTH DUEFIRST PAYMENT DUE DATEFOR PAYROLL DEDUCTIONEMPLOYEE IDNUMBERDEDUCTIONSEMPLOYEE IS:APPLICANTCO-APPLICANTOTHER (IF OTHER, COMPLETE BELOWEMPLOYEE NAMEEMPLOYER NAMEFOR CREDIT CARDS (Not applicable in North Carolina)CREDIT CARD COMPANYACCOUNT NUMBEREXPIRATION DATESECURITY VERIFICATION THE PAYOR REQUIRE A PHYSICAL RECORD OF THIS TRANSACTION ? (Y/N) APPLICABLE, TO ENSURE ACCURACY, A VOIDED CHECK OR DEPOSIT SLIP SHOULD BE ATTACHED TO THIS HEREBY REQUEST AND AUTHORIZE THE COMPANY INDICATED ON THIS APPLICATION TO DEBIT/CREDIT MY/OUR BANK ACCOUNT AS PAYMENTS ON MY/OUR POLICY BECOMEDUE. I/WE AGREE THAT IF A DEBIT/CREDIT IS DISHONORED, THE BANK SHALL HAVE NO LIABILITY EVEN IF THE DISHONORED DEBIT/CREDIT RESULTS IN THE FORECLOSURE OFINSURANCE.)

5 THIS AUTHORITY IS TO REMAIN IN FULL FORCE UNTIL THE COMPANY AND THE BANK NAMED ABOVE HAVE EACH RECEIVED WRITTEN NOTICE FROM ME/US OF ITSTERMINATION IN SUCH TIME AND SUCH MANNER AS TO AFFORD THE COMPANY AND THE BANK REASONABLE OPPORTUNITY TO ACT ON information WILL BE USED BY THE COMPANY ONLY FOR THE PROCESSING OF INSURANCE PREMIUMS AND WILL BE KEPT STRICTLY : ALL BANK DRAFT RETURNS FOR INSUFFICIENT FUNDS OR ACCOUNT CLOSED MAY BE SUBJECT TO A FEE. INDIVIDUAL STATE LAWS MAY LIMIT THIS SIGNATUREAUTHORIZED SIGNATUREDATEDATECOPYRIGHT OWNER CODEEDITION DATEFORM NUMBERLOC #FORMS AND ENDORSEMENTSVEH #BOAT #ITEM #FORM NAMEATTACHMENTSWINDSTORM LOSS MITIGATIONRESIDENCE BASED BUSINESS SUPPSTATE SUPPLEMENT(S) (If applicable)SOLID FUEL SUPPLEMENTPROTECTION DEVICE CERTIFICATEPHOTOGRAPHREPLACEMENT COST ESTIMATERECREATIONAL VEHICLE APPLEAD FREE PAINT CERTIFICATIONFLOOD EXCLUSION NOTICECERT. OF MOBILE HOME TIE DOWNSACORD 88 (2007/11)AGENCY CUSTOMER ID:Page 4 of 4 REMARKSINITIALS:BINDER/SIGNATURENATIONAL PRODUCER NUMBERPRODUCER'S SIGNATUREDATEAPPLICANT'S SIGNATUREAPPLICABLE IN COLORADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OFCOVERAGE, TO EVALUATE THE ISSUANCE OF THE INSURANCE BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BYWRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:COVERAGE IS NOT BOUNDNOON12:01 AMTHIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICYCONDITIONS.

6 THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY,THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THECOMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION . THISINSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) INCURRENT USE BY THE DATEEFFECTIVE DATEINSURANCE BINDERAPPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THEINFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THISINFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM information ABOUT YOU, INCLUDING information FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAYBE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE ANDSUBSEQUENT AMENDMENTS AND RENEWALS.

7 SUCH information AS WELL AS OTHER PERSONAL AND PRIVILEGEDINFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIESWITHOUT YOUR AUTHORIZATION. CREDIT SCORING information MAY BE USED TO HELP DETERMINE EITHER YOURELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITHTHE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL information IN OUR FILES ANDCAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OURPRACTICES REGARDING SUCH information IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FORINSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO of the Notice of information Practices (Privacy) has been given to the applicant. (Not applicable in all states, consult your agentor broker for your state's requirements.)ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES ANAPPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE information , OR CONCEALSFOR THE PURPOSE OF MISLEADING information CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.

8 (Notapplicable in CO, FL, HI, MA, NE, OH, OK, OR or VT; in DC, LA, ME, TN, VA and WA, INSURANCE benefits may also be denied)IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES ASTATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING information IS GUILTYOF A FELONY OF THE THIRD MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMCONTAINING ANY MATERIALLY FALSE information , OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATIONCONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAYSUBJECT THE PERSON TO CRIMINAL AND CIVIL 88 (2007/11)AGENCY CUSTOMER ID.