ACORD HOMEOWNER APPLICATION

1 PART COMP YEARYEARS INYEARS W/YEARS W/CURR OCC CURR EMPL PRIOR EMPLYEARS INYEARS W/YEARS W/CURR OCC CURR EMPL PRIOR EMPLTMMANNEDSECURITYOFF PREMISESTHEFT EXCLOTHER:DATE (MM/DD/YYYY)PHONEPRODUCERAPPLICANT S NAME AND MAILING ADDRESS (Include county & ZIP+4)(A/C, No, Ext):FAXNAIC CODEFACILITY CODE(A/C, No):POLICY #DATE ATHOME PHONE #CO/PLANCURR RESEFFECTIVE DATEEXPIRATION DATEBUSINESS PHONE #CODE:SUBCODE:AGENCY CUSTOMER IDPREVIOUS ADDRESS (If less than 3 years)YRS ATLOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP)PREVADDRAPPLICANT S OCCUPATIONMARAPPLICANT S EMPLOYER NAME AND ADDRESSDATE OF BIRTHSOCIAL SECURITY #(State nature of business if self-employed)STATCO-APPLICANT S OCCUPATIONMARCO-APPLICANT S EMPLOYER NAME AND ADDRESSDATE OF BIRTHSOCIAL SECURITY #(State nature of business if self-employed)

2 STATHO FORMDWELLINGOTHERPERSONALLOSS OF USEPERSONALMEDICALSTRUCTURESPROPERTYLIAB ILITYPAYMENTS$$$$$$EST TOTAL PREMIUM$DEPOSIT$BALANCE$MAIL POLICY TO:ACCOUNT #:BILLINGIF DIRECT BILL:IF APPLICANT BILL:YR BUILT# ROOMSMARKET VALUESTRUCTURE TYPEUSAGE TYPE# FAM-#PURCHASEILIES HSEHLDDATE/PRICERES$SQ FT# APTSREPLACEMENT COST$RENOVATION TYPENUMBER OFTERRPREMPROTECTDISTANCE TOPROTECTION DEVICE TYPEHEAT TYPECODEGROUPCLASSFIREUNITS INFIREHYDRANTDIVSFIRE DIVSTATIONFIRE/EC RATEFIRE DISTRICT/CODE NUMBEROIL STORAGE TANK LOCATIONDWELLING LOCATIONSTORM SHUTTERSSWIMMINGOCCUPIED BYPOOLHOUSEKEEPING CONDITIONINSPECTED?

3 TAX CODEFOUNDATIONBLDG CODE# WKSOCCUPIED DAILY?WIND CLASSRATINGROOF TYPEGRADERENTEDNOYESSPRINKLERIF REPLACEMENT COST APPLIES:BASEMENTGARAGEBREEZEWAYDAYEVEDAY EVEALL PERILEACH OCCURRENCEEACH PERSONWIND/HAILTHEFTNAMEDHURRICANE *REPLACEMENT COST DWELLINGREPLACEMENT COST CONTENTSENTER OTHER ENDORSEMENT(S)AGENTDIRECT BILLBILL APPLICANTOTHER:FULL PAYAPPLICANTAGENCY BILLBILL MORTGAGEEOTHER:OTHER:PLASTICFRAMEFARMSID INGASBESTOSMASONRYDWELLINGTOWNHOUSEPRIMA RYCOCSIDINGMASONRYFIRE RESAPARTROWHOUSESECONDARYUNOCCVENEERALUM INUMCONDOCO-OPSEASONALVACANTSIDINGNONEWI RINGSYSTEMSMOKETEMP BURGLAR PRIMARY:PLUMBINGFTMI CENTRALSECONDARY.

4 HEATINGDIRECTROOFINGLOCALEXTERIOR PAINTDEADBOLTVISIBLE TO NEIGHBORSYESNOYESHURRRESGLASSYESWITHINWI THIN PROTAPPROVEDABOVEOWNERACITY LIMITSSUBURBFIRE EXTINGUISHERFENCEGROUNDIN-GROUNDNONOWITH INDIVINGTENANTBFIRE DISTBOARDSEMI-CLOSEDRESISTIVEYESNORESIST IVEOTHERCLASSSPECOPENNONEACORD4041 ATTACHED42 NON-SMOKERCHIMNEYSPRE-FABPARTIALLIGHTNIN GHEARTHSSQ FTSQ FTSQ FTFULLPROTECTIONRATING CREDITSFIREPLACESHOW LONG HAVE YOU KNOWN THE APPLICANT?DATE AGENT LAST INSPECTED PROPERTY:* Not Applicable in NCAPPLICANT INFORMATIONCOVERAGES/LIMITS OF LIABILITYDED (Type & Amount)ENDORSEMENTSPREMIUMACORD 610 Attached (NOT APPLICABLE IN NC)PAYMENT PLANRATING/UNDERWRITINGPLEASE COMPLETE REVERSE SIDEACORD 80 (2001/04) ACORD CORPORATION 1981 ACORDHOMEOWNER APPLICATIONANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES (Including day/child care)EXPLAIN ALL "YES" RESPONSES IN REMARKSYESNO EXPLAIN ALL "YES" RESPONSES IN REMARKS (Except question 15, 16 and 17)

5 YES NOANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURINGAPPLICANT SIF YES, INDICATE BELOWTHE LAST 3 YEARS, AT THIS OR AT ANY OTHER LOCATION?INITIALS:DATETYPEDESCRIPTION OF LOSSAMOUNTPRIOR CARRIERPRIOR POLICY NUMBEREXPIRATION DATERISK NEW TO AGENCYINT #NAME AND ADDRESSLOAN NUMBERINT #NAME AND ADDRESSLOAN NUMBERFOR COMPANY USE ONLYINSURANCE BINDEREFFECTIVE DATEEXPIRATION DATETIMEDATEAPPLICANT SPRODUCER SSIGNATURESIGNATUREYESNOYESNOMORTG EADDL INTMORTG EADDL INTSTATE SUPPLEMENT(S)(If applicable)PROTECTION DEVICE CERTIFICATEPERS EXCESS/ umbrella APPINLAND MARINE APPLICATIONREPLACEMENT COST ESTIMATERECREATIONAL VEHICLE APPPHOTOGRAPHWATERCRAFT APPLICATIONLEAD FREE PAINT CERTIFICATIONSOLID FUEL SUPPLEMENTHOME BASED BUSINESS SUPPEARTHQUAKE APPLICATION12:01 AMNOONCOVERAGE IS NOT BOUNDIS PROPERTY SITUATED ON MORE THAN FIVE ACRES?

6 (If yes, describe land use)IF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCE BEENOBTAINED FOR THE TANK? (Give First Party and limit, and Third Party and limit)ANY RESIDENCE EMPLOYEES? (Number and type of full and part time employees)PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTIONWITH THIS APPLICATION AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OURAGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES.

7 YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CANREQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLEUPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO COVERAGE DECLINED, CANCELLED OR NON-RENEWEDDURING THE LAST 3 YEARS? NOT APPLICABLE IN MOHAS APPLICANT HAD A FORECLOSURE, REPOSSESSION ORBANKRUPTCY DURING THE PAST FIVE YEARS?ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES?(Note breed and bite history)IS PROPERTY W/IN 300 FT OF A commercial ORNON-RESIDENTIAL PROPERTY?

8 WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN APRIVATE RESIDENCE AND THEN CONVERTED?14. DURING THE LAST FIVE YEARS (TEN YEARS IN RHODE ISLAND), ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THECRIME OF ARSON? (In RI, failure to disclose the existence of an is a misdemeanor punishable by a sentence of up to one3. ANY FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC?year of imprisonment.)RENTERS ANDCONDOS ONLY:4. ANY OTHER RESIDENCE OWNED, OCCUPIED OR RENTED?15. IS THERE A MANAGER ON THE PREMISES?5. ANY OTHER INSURANCE WITH THIS COMPANY?

9 (List policy numbers)16. IS THERE A SECURITY ATTENDANT?6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?17. IS THE BUILDING ENTRANCE LOCKED? ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS?IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTION?(Give estimated completion date and dollar value) IS HOUSE FOR SALE? IS PROPERTY LOCATED WITHIN TWO MILES OF TIDAL WATER?22. IS THERE A TRAMPOLINE ON THE PREMISES? DOES APPLICANT OWN ANY RECREATIONAL VEHICLES(SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATVS, ETC)?24. ANY LEAD PAINT HAZARD?(List year, type, make, model) IS BUILDING RETROFITTED FOR EARTHQUAKE (If applicable)IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION .

10 THIS INSURANCE IS SUBJECTTO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THECOMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANYBY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHENREPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE APREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY.