ACORD PROPERTY SECTION DATE (MM/DD/YYYY)

1 TMDATE (MM/DD/YYYY)PHONEAGENCYAPPLICANT(A/C, No, Ext):(FirstFAXN amed(A/C, No):Insured)EFFECTIVE DATEEXPIRATION DATEPAYMENT PLANAUDITFORCOMPANYUSE ONLYCODE:SUB CODE:AGENCYCUSTOMER ID:PREMISES #:STREET ADDRESS:BUILDING #:BLDG DESCRIPTION:BLKTINFLATIONSUBJECT OF INSURANCEAMOUNTCOINS % VALUATIONCAUSES OF LOSSDEDUCTIBLEFORMS AND CONDITIONS TO APPLYCOVGUARD %ADDITIONAL INFORMATIONBUSINESS INCOME / EXTRA EXPENSEBUSINESS INCOME W/O EXTRA EXPENSEEXTRA EXPENSETYPE OF BUSINESSORDINARY PAYROLLPOWER/HEATEXT PERIODTUITION FEESOFF PREM POWERDEPEND PROPELEC MEDIAMO PERIODORD OR LAWMAX PERIODNAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONDISTANCE TOCONSTRUCTION TYPEFIRE DISTRICT/CODE NUMBERPROT CL# STORIES # BASM TSYR BUILTTOTAL AREAHYDRANTFIRE STATBLDG CODETAX CODEROOF TYPEOTHER OCCUPANCIESBUILDING IMPROVEMENTSGRADEWIND CLASSRIGHT EXPOSURE & DISTANCELEFT EXPOSURE & DISTANCEREAR EXPOSURE & DISTANCEBURGLAR ALARM TYPECERTIFICATE #EXPIRATION DATEEXTENTGRADEBURGLAR ALARM INSTALLED AND SERVICED BY# GUARDS/WATCHMENPREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)% SPRNKFIRE ALARM MANUFACTURERRANK:NAME AND ADDRESS:REFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERINTERESTLOCATION:BUILDING:SCHEDULE D ITEM NUMBER:OTHER:ITEM DESCRIPTION.

2 ANY OTHER LOCA-ANY OTHER LOCA-PREMISES NOT OWNEDPREMISES/TION DECLAREDTION ACQUIREDOR ACQUIREDBUILDINGSUBJECT OF INSURANCEAT INCEPTIONAFTER INCEPTIONLIMITDIRECT BILLAGENCY BILLNON MFGEXCLINCL$DEDDAYS $STUDENTSPOWER% COINMFG90 DAYS$OTHER EDWATERCONT LOCSERV/INCMINING180 DAYSDAYSLIMITCOMMREC LOC(DESCR BELOW)% COINS$MFG LOCDAYSLDR LOC (DESC BELOW)EXTRADAYS PERIOD RESTEXPENSELIMIT LOSS PAY%%%%FTMIWIRING, YR:PLUMBING, YR:ROOFING, YR:HEATING, YR:HEATING BOILER ON PREMISES?YESNOSEMI-OTHER:RESISTIVEOTHERI F YES, IS INSURANCE PLACED ELSEWHERE?YESNORESISTIVECENTRAL STATIONWITH KEYSCLOCK HOURLYCENTRAL STATIONLOCAL GONGLOSSPAYEEMORT-GAGEEREPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHSPREMISES INFORMATIONADDITIONAL INTERESTSVALUE REPORTING INFORMATIONACORD 140 (2002/09)ATTACH TO APPLICANT INFORMATION SECTION ACORD CORPORATION 1985 ACORDPROPERTY SECTIONPREMISES #:STREET ADDRESS:BUILDING #:BLDG DESCRIPTION.

3 BLKTINFLATIONSUBJECT OF INSURANCEAMOUNTCOINS % VALUATIONCAUSES OF LOSSDEDUCTIBLEFORMS AND CONDITIONS TO APPLYCOVGUARD %ADDITIONAL INFORMATIONBUSINESS INCOME / EXTRA EXPENSEBUSINESS INCOME W/O EXTRA EXPENSEEXTRA EXPENSETYPE OF BUSINESSORDINARY PAYROLLPOWER/HEATEXT PERIODTUITION FEESOFF PREM POWERDEPEND PROPELEC MEDIAMO PERIODORD OR LAWMAX PERIODNAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONDISTANCE TOCONSTRUCTION TYPEFIRE DISTRICT/CODE NUMBERPROT CL# STORIES # BASM TSYR BUILTTOTAL AREAHYDRANTFIRE STATBLDG CODETAX CODEROOF TYPEOTHER OCCUPANCIESBUILDING IMPROVEMENTSGRADEWIND CLASSRIGHT EXPOSURE & DISTANCELEFT EXPOSURE & DISTANCEREAR EXPOSURE & DISTANCEBURGLAR ALARM TYPECERTIFICATE #EXPIRATION DATEEXTENTGRADEBURGLAR ALARM INSTALLED AND SERVICED BY# GUARDS/WATCHMENPREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)% SPRNKFIRE ALARM MANUFACTURERRANK:NAME AND ADDRESS:REFERENCE #:CERTIFICATE REQUIREDINTEREST IN ITEM NUMBERINTERESTLOCATION:BUILDING:SCHEDULE D ITEM NUMBER:OTHER:ITEM DESCRIPTION.

4 NON MFGEXCLINCL$DEDDAYS $STUDENTSPOWER% COINMFG90 DAYS$OTHER EDWATERCONT LOCSERV/INCMINING180 DAYSDAYSLIMITCOMMREC LOC(DESCR BELOW)% COINS$MFG LOCDAYSLDR LOC (DESC BELOW)EXTRADAYS PERIOD RESTEXPENSELIMIT LOSS PAY%%%%FTMIWIRING, YR:PLUMBING, YR:ROOFING, YR:HEATING, YR:HEATING BOILER ON PREMISES?YESNOSEMI-OTHER:RESISTIVEOTHERI F YES, IS INSURANCE PLACED ELSEWHERE?YESNORESISTIVECENTRAL STATIONWITH KEYSCLOCK HOURLYCENTRAL STATIONLOCAL GONGLOSSPAYEEMORT-GAGEEANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNINGANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES.

5 (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)ADDITIONALPREMISES INFORMATIONADDITIONAL INTERESTSREMARKSACORD 140 (2002/09)