ACORD 0080 2013-09

1 CIVIL UNION (if applicable)MARITAL STATUS * /CIVIL UNION (if applicable) ACORD 80 ( 2013 /09)HOW LONG HAVE YOU KNOWN THE APPLICANTFORM NAMEITEM #BOAT #VEH #FORMS AND ENDORSEMENTS (Attach ACORD 829, Forms and Endorsements Schedule, if more space is required)LOC #FORM NUMBEREDITION DATECOPYRIGHT OWNER CODESUSTAINEDACTUAL LOSSOF USE**Not Applicable in North CarolinaNamed Storm Percentage Deductible in North CarolinaHO FORM #:$$$$$% MAXHURRICANE**HURRICANE*$$$$AMOUNTTYPE%% %%PERCENT$$$$DEDUCTIBLEAMOUNTLIMITINCLUD EDINCLUDEDINCLUDEDOPTIONREPL COST - CONTENTSREPL COST - DWELLINGREPL COST - FULL VALUECOVERAGE* Includes Dwelling, Other Structures, Personal Property, Loss of UseTYPE%%%ANNUALNAMEDTHEFTWIND / HAILBASEPREMIUM%DEDUCTIBLEPERCENTMEDICAL PAYMENTS EA PERPERSONAL LIABILITY EA OCCLOSSPERSONAL PROPERTYCOVERAGELIMITBLANKET *DWELLINGOTHER STRUCTURESPREMIUM$$$$$$$$$$$$$$COVERAGES / LIMITS OF LIABILITY LOC #.

2 DATE AGENT LAST INSPECTED PROPERTYEFFECTIVE DATESTATUS OF TRANSACTIONRENEWNEWPOLICY CHANGEPOLICY CHANGETIMEAMPMC heck if same as Applicant* This field may not be utilized for policyholders applying for residential property insurance in OF BIRTHSOCIAL SECURITY #MARITAL STATUS * /DATE OF BIRTHSOCIAL SECURITY #* This field may not be utilized for policyholders applying for residential property insurance in WITH PREVIOUS EMPLOYER:YEARS IN CURRENT OCCUPATION:YEARS WITH PREVIOUS EMPLOYER:YEARS IN CURRENT OCCUPATION:YRS WITH CURRENT EMPLOYER:YRS WITH CURRENT EMPLOYER:RENTEDOWNEDC heck if same as mailing addressCURRENT RESIDENCENAMED insured (S) policy NUMBEREFFECTIVE DATEEXPIRATION DATECARRIERNAIC CODEPLANFACILITY CODEDATE AT CURRENT RESIDENCE:PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSCO-APPLICANT'S ADDRESSCO-APPLICANT'S NAME ( first , Middle, Last)PRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS.

3 CO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)CO-APPLICANT'S EMPLOYER NAME AND ADDRESSPHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSAPPLICANT'S EMPLOYER NAME AND ADDRESSAPPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)YEARS AT PREVIOUS ADDRESS (if less than three years):PREVIOUS ADDRESSSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:APPLICANT'S NAME ( first , Middle, Last)APPLICANT'S MAILING ADDRESSAPPLICANT INFORMATIONFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE: code :AGENCY CUSTOMER ID:ADDRESS:E-MAILThe ACORD name and logo are registered marks of ACORDPage 1 of 6 1981- 2013 ACORD CORPORATION.

4 All rights APPLICATIONDATE (MM/DD/YYYY) ACORD 80 ( 2013 /09)YEARS, AT THIS OR ANY LOCATION?ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURINGTHE LAST$APPLICANT'SINITIALS:IF YES, INDICATE BELOWY / NLOSS HISTORY(Y / N)DISPUTEIN(C)OMPANY(A)GENTLOSS TYPE$$$ENTERED BYDESCRIPTION OF LOSSLOSS DATEAMOUNT PAIDCAT #NO PRIOR COVERAGEPRIOR policy NUMBERPRIOR CARRIERPRIOR COVERAGEEXPIRATION DATELOCATION SCHEDULELOC #STREETCITYSTATEZIP + 4 COUNTYPage 2 of 6 SEMI-RESISTIVEWIND CLASSRESISTIVESTORM SHUTTERSBAHURRICANE RESISTIVE GLASSWINDSTORMINDOORS ABOVE GROUND NO MASONRY FLOORNONEFUEL STORAGE TANK LOCATIONOUTDOORS ABOVE GROUNDINDOORS ABOVE GROUND MASONRY FLOOROUTDOORS BELOW GROUNDFUEL LINE LOCATIONUNDER GROUNDTHROUGH FOUNDATIONDIVING BOARDSLIDEIN

5 GROUNDABOVE GROUNDAPPROVED FENCESWIMMING POOLNONERENOVATIONSWIRINGPLUMBINGHEATING ROOFINGEXTERIOR PAINTPARTCOMPYEARCLASSSPECIFICRATINGCLOS EDNONEFOUNDATIONOPENIN FIRE DISTRICTIN CITY LIMITSIN PROT SUBURBDWELLING LOCATIONRATING CREDITSNON-SMOKERLIGHTNING PROTECTIONMANNED SECURITYOFF PREMISE THEFT EXCLRESIDENTS# ROOMS# APARTMENTS# FAMILIES# HOUSEHOLD# WEEKS RENTEDTAX CODEBLDG code GRADEINSPECTED (Y/N):FIREPLACES (Enter # or 0 for none)PRE-FABCHIMNEYSHEARTHSWOOD STOVE INSERTSQ FTBREEZEWAY AREASQ FTGARAGE AREASQ FTBASEMENT AREASQ FTTOTAL LIVING AREA$REPLACEMENT COST$MARKET VALUEYEAR BUILTNEIGHBORSROADROOF MATERIALROOF CONDITIONAVERAGEEXCELLENTGOODBELOW AVGANY KNOWN LEAKS?

6 (Y/N)BELOW AVGGOODEXCELLENTAVERAGEPLUMBING CONDITIONTOWNHOUSEROWHOUSEAPARTMENTDWELL INGCONDOMINIUMCO-OPRESIDENCE TYPECONSTRUCTION TYPEMASONRY VENEERMASONRYFRAME%OCCUPIED DAILYVISIBLE TOVISIBLE FROMSECURITYEIFSS (on studs)SHINGLESTUCCOALUMINUM SIDINGVINYL SIDING / PLASTICSIDINGCEDAR, WOOD,EIFSCB (on cinder block)YEAR EIFS INSTALLED:%FIRE DIST CODEFIRE DISTRICT NAMEDISTANCE TO TIDAL WATERM ilesFeetCOURSE OF CONSTRUCTIONRENOVATIONBUILDERS RISKRECONSTRUCTIONKNOB & TUBEWIRINGLAST INSPECTED DATECOPPERALUMINUMFUSESELECTRICAL SYSTEMSCIRCUIT BREAKERSNUMBER OF AMPSSPRINGDOOR LOCKDEADBOLTPARTIALSPRINKLERFULLDATE HEATING SYSTEM LAST SERVICED.

7 SECONDARY HEATNONEPRIMARY HEATNONELOCALDIRECTCENTRALBURGTEMPSMOKES YSTEMPROTECTION DEVICE TYPEY / NFIRE EXTINGUISHERPROT CLASSTERRITORY# UNITS FIRE DIV# FIRE DIVISIONSFIRE STATIONMIFTFIRE HYDRANTDISTANCE TO$PURCHASE DATEPURCHASE PRICEVACANTTENANTOWNERUNOCCUPIEDOCCUPANC YUSAGE TYPESEASONALPRIMARYSECONDARYFARMHOUSEKEE PING CONDITIONAVERAGEEXCELLENTGOODBELOW AVGRATING / UNDERWRITING LOC #:PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)FINANCE COMPANYY/NPREMIUM FINANCED ?

8 MORTGAGEEINSUREDPAYORPRE-AUTHORIZED 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:$$AGENCY CUSTOMER ID: ACORD 80 ( 2013 /09)(Not applicable in NC)EQUIP BREAKDOWNBUSINESS PROPAWAY FROM HOME$DED$$LIMITINCLIMIT$LIMIT$LIMIT$LIMI T$INCREASEINFLATION GUARD%$$$LOSS ASSESSMENTLIMIT$LIMITPROP DESC:CONST MATERIAL:MINE SUBSIDENCE$WORKERSCOMPENSATION -FULL TIMEINSERVANTMED PAY (Y/N):ANY OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION, OWNED, OCCUPIED OR RENTED?

9 APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS? APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS? OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) policy NUMBERPOLICY NUMBERLINE OF BUSINESSLINE OF ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS?(Missouri applicants - Do not answer this question)GENERAL INFORMATIONY / NEXPLAIN ALL "YES" RESPONSESPage 3 of 6 AGENCY CUSTOMER ID:PREMIUMTYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DEDUCTIBLEDESCRIPTIO NY / N:OPTSLIMITCOVERAGE TYPECODETERR:APPL TO(Applicable only in CA, MT, NV, NH, NJ, NY, ND, OH,OR, WA, WV and WY)# OF EMPLOYEES.

10 (Not applicable in Arkansas)YESWINDSTORM EXCLLIMIT$WATERCRAFTLIABILITYWATERCRAFTP HYSICAL DAMAGELIMIT$LIMIT$INCLUDED$WATER BACKUP OFSEWERS & DRAINSINCR$AGG$UNSCHEDULEDJEWELRY,WATCHE S, FURSLIMIT$INCLUDEDUNIT-OWNERSADDITIONS &ALTERATIONSSPECIAL COVERAGEINCLUDEDSINK HOLECOLLAPSELIMIT$INCLUDEDREFRIGERATEDFO OD PRODUCTS$LIMIT$PREMIUMCOVERAGE TYPECOVERAGE INFORMATION$$$$$$$$$$$$INCRTOTALINCRTOTA LINCRTOTALINCRTOTALINCR$$$$$$$$$$$LIMIT$ $$$$$$$$MED PAY (Y/N):$PREMIUMINCLUDEDPLANTS, SHRUBS &TREESSTRUCTURE DESC:LIMITOTHERSTRUCTURES -INDIVIDUAL STRUCBUS/STRUCT DESC:STRUCT TYPE:MED PAY (Y/N) :TERR:OT.