AGENCY APPLICANT/FIRST NAMED INSURED …

1 ACORD 810 (2007/07) 2005-2007 ACORD CORPORATION. All rights COVERAGESTUITION FEES$STUDENTS$OTHER EDSERV/INCNAME(S) AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPEXTRA EXPENSEDAYS PERIOD RESTLIMIT LOSS PAY%%%%LIMITED FORMBROAD FORMDEPEND PROPCOINCONT LOCREC LOCMFG LOCLDR LOC (DESC BELOW)CIVIL AUTHDAYSORD OR LAWDAYSELEC MEDIADAYSDED$POWER/HEAT% COINSMININGMFGNON MFGTYPE OF BUSINESS$180 DAYS90 DAYSINCLEXCLORDINARY PAYROLLMAX PERIODDAYSEXT PERIODMO PERIODLIMITCOMM (DESCR BELOW)WATERPOWEROFF PREM POWERPREMISES INFORMATIONBUSINESS INCOME /RENTAL VALUEBUILDING #:PREMISES #:BUSINESS INCOME / extra EXPENSEBUSINESS INCOMEW/O extra EXPENSEEXTRA EXPENSERENTAL VALUEDATE (MM/DD/YYYY)BUSINESS INCOME / extra EXPENSE / RENTAL VALUESUPPLEMENT TO PROPERTY SECTIONAGENCY CUSTOMER ID.

2 The ACORD name and logo are registered marks of ACORDAGENCYAPPLICANT/FIRST NAMED INSUREDPOLICY NUMBERCARRIERNAIC CODEATTACH TO ACORD 140 Page 1 of 2 ACORD 810 (2007/07)OTHER COVERAGESTUITION FEES$STUDENTS$OTHER EDSERV/INCNAME(S) AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPEXTRA EXPENSEDAYS PERIOD RESTLIMIT LOSS PAY%%%%LIMITED FORMBROAD FORMDEPEND PROPCOINCONT LOCREC LOCMFG LOCLDR LOC (DESC BELOW)CIVIL AUTHDAYSORD OR LAWDAYSELEC MEDIADAYSDED$POWER/HEAT% COINSMININGMFGNON MFGTYPE OF BUSINESS$180 DAYS90 DAYSINCLEXCLORDINARY PAYROLLMAX PERIODDAYSEXT PERIODMO PERIODLIMITCOMM (DESCR BELOW)

3 WATERPOWEROFF PREM POWERANY 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 CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable 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)

4 IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY ORANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FORTHE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME ANDMAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PREMISES INFORMATIONBUSINESS INCOME /RENTAL VALUEBUILDING #:PREMISES #:BUSINESS INCOME / extra EXPENSEBUSINESS INCOMEW/O extra EXPENSEEXTRA EXPENSERENTAL VALUEAGENCY CUSTOMER ID:Page 2 of 2