AGENCY CUSTOMER ID: BUSINESS OWNERS SECTION

1 REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)ACORD 160 (2014/12) AGENCY CUSTOMER ID:24 HOUR OPERATIONSEND TIME:START TIME:DOES THE OPERATION HAVE HOURS AFTER 9:00 AND/OR 24 HOUR OPERATIONS? EQUIPMENTSMALL TOOLSEQUIPMENTINSTRUCTION GIVEN (Y/N)LARGE EQUIPMENTSMALL TOOLSTYPE OF EQUIPMENTDO YOU RENT OR LOAN EQUIPMENT TO OTHERS? ADDITION TO YOUR PRIMARY NATURE OF BUSINESS , ARE YOU ALSO INVOLVED IN THE MIXING OF OTHERS PRODUCTS? ADDITION TO YOUR PRIMARY NATURE OF BUSINESS ARE YOU ALSO INVOLVED IN THE MANUFACTURE, RELABELING OR REPACKAGING OF OTHERSPRODUCTS? INTERESTTYPE OF BUSINESS OR LOCSTREET, CITY, STATE, ZIPDO YOU OWN OR OPERATE ANY OTHER BUSINESS ?

2 CARRIED (Y/N)LEASE FROMWORKERSCOMPENSATIONCOVERAGE CARRIED (Y/N)LEASE TODO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? YOU OBTAIN AND VERIFY CERTIFICATES OF INSURANCE OBTAINED FROM SUBCONTRACTORS, MANUFACTURERS AND/OR SUPPLIERS? (If "NO", explain) (Y/N)EXTENT OF SPONSORSHIP:OVER 1813 - 1812 & UNDERAGE GROUPTYPE OF SPORTCONTACTSPORT (Y/N)EXTENT OF SPONSORSHIP:OVER 1813 - 1812 & UNDERAGE GROUPTYPE OF SPORTARE ATHLETIC TEAMS SPONSORED? / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL? ( landfills, wastes, fuel tanks, etc) INFORMATIONY / NEXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISEPREMIUMPREMIUM$MINIMUM PREMIUM$$$$$$TOTAL ESTIMATED PREMIUM$$$$TAXES SURCHARGESCHEDULE CREDITSOPTIONAL COVERAGESLIABILITYDEDUCTIBLE CREDITSPERSONAL property $BUILDINGPREMIUMSPECIALSTANDARDP OLICY TYPEEFFECTIVE DATENAIC CODECARRIERPOLICY NUMBERFIRST NAMED INSUREDAGENCY NAMEDATE (MM/DD/YYYY) BUSINESS OWNERS SECTION 1993-2014 ACORD CORPORATION.

3 All rights to ACORD 125 The ACORD name and logo are registered marks of ACORDACORD 160 (2014/12)SYMBOLPage 2 of 6$$$$$$$$$$$$$$$$$$$$$$$$$$$$$Y/NTERROPT IONS$$DESCRIPTION OFCREDIT / SURCHARGE AMOUNTAPPLIESTODESCRIPTIONCODELIMIT$DEDU CTIBLETYPEPREMIUMDEDUCTIBLECOVERAGELIABI LITY ADDITIONAL COVERAGES - POLICY LEVEL$$$$$$$$$$$$$$$$PREMIUMCOLLISION$$L EGALLIABILITYDIRECT BASISPRIMARYEXCESSLOC #DEDUCTIBLEPER AUTOMAXIMUMDED PER LOSSLIMIT PER LOCATION# OF AUTOS$$$PERILSSPECIFIEDCOMP / OTCAGENCY CUSTOMER ID:$$$$$$$$$$$$$$$$$$$FORM DATEFORM NUMBERDATE:RETROACTIVE$$$$$$$$$$$$$AUTO - NON-OWNED$$COMPREHENSIVE / OTCCOLLISIONGARAGE PHYSICAL DAMAGEGARAGE KEEPERS LIABILITY$$$MOBILE EQUIPMENT SUBJECTTO MOTOR VEHICLE LAWSMEDICAL PAYMENTS$$$$LIQUOR LIABILITYGENERAL AGGREGATEPER PERSONOTHER:$FREIGHT OR PASSENGERELEVATORS INSPECTION FEE$EXTENDED EMPLOYEEDISHONESTYEMPLOYEE BENEFITS LIABILITYAUTO - HIRED LIABILITYAUTO - HIRED PHYSICAL DAMAGEPROPERTY DAMAGE$BODILY INJURY$DATE:$$RETROACTIVE$$DIRECTORS & OFFICERSTENANTS LEGAL LIABILITYDATE.

4 TOTAL AMOUNT$$$$$$$$$$$EMPLOYMENT PRACTICESLIABILITY (EPLI)INCLUDEDPREMIUMDEDUCTIBLEPERSONAL & ADVERTISINGINJURYPRODUCTS & COMPLETEDOPERATIONSRETROACTIVECOVERAGEPR OFESSIONAL LIABILITYMEDICAL EXPENSE (per person)OCCURRENCEAGGREGATEBODILY INJURY& PROPERTYDAMAGELIABILITY COVERAGES - POLICY LEVEL#BLKT#BLKTDEDUCTIBLE TYPE:DEDUCTIBLE TYPE:$DED$DEDINFL %PREMLEVELPOLLEVELPage 3 of 6$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$B ASIC$$SPOILAGEEQUIPMENT BREAKDOWNBROAD$$$DATA / MEDIAEXTRA EXPENSEEQUIPMENTEDP / COMPUTER$$$$$$DEBRIS REMOVALCOMBINED DEMOLITION COSTAND INCREASED CONST COSTBUSINESS INCOME WITHEXTRA EXPENSEBUSINESS INCOME FROMDEPENDENT PROPERTIES$$$$$$$$$$ BUSINESS INCOMEBUSINESS INCOME CHANGES -TIME PERIOD$ACTUAL LOSS SUSTAINEDNO.

5 OF MONTHSFORM DATEFORM NUMBERTOTAL AMOUNT(including Base Limit)INCLUDEDPREMIUMDEDUCTIBLE$$COLLAPS E DUE TOHYDRO-STATIC PRESSURETHEFT OF BLDG MATERIALSBUILDERS RISK ONLYOWNER'S MISCELLANEOUSREAL PROPERTYMONEY & SECURITIES -OUTSIDEWELFARE & PENSION PLAN(ERISA)$$$$FORGERY OR ALTERATION$EMPLOYEE DISHONESTYMONEY & SECURITIES - INSIDE$CRIME$ owner 'S LOSS ASSESSMENT$CONDO UNIT$BAILEES LIABILITYANIMAL COVERAGE%MASONRY VENEER:RETROFIT TYPE:TERR:%$EARTHQUAKE$ACCOUNTS RECEIVABLECOVERAGEPROPERTY COVERAGESSPECIFIC PROPERTYGRADE DEVELOPED FORINSPECTED? (Y/N)FVRCACVRCYEAR BUILTPROPPERSINFL %ATION:VALU-% COINS$LIMITFVRCACVRCCONSTRUCTION TYPEDEDUCTIBLE TYPE:DEDUCTIBLE TYPE:$DED$DEDBLDG%SPRNKATION:VALU-% COINS$LIMITBASEMENT PRESENT?

6 (Y/N):IS IT FINISHED? (Y/N):STORIES#GRADEBLDG CODETAX CODEHEATINGYEARPLUMBINGYEARROOFINGYEARWI RINGYEARIMPROVEMENTSBUILDINGPROPERTYROOF TYPECOMMUNITYWIND CLASSRESISTIVESEMI-RESISTIVEPREMISESBLAN KET RATE (Y / N):FIRE DISTRICT CODE NUMBERCHECK IF PRIMARY PREMISESDISTANCE TOHYDRANTFIRE STATFTMIRATE TERRITORYPROT CLASSTOTAL PAYROLL$ANNUAL SALES / RECEIPTS$FIRE DISTRICTRATE GROUPRATE #CLASS CODEDISTANCE:DISTANCE:DISTANCE:DISTANCE: RIGHT EXPOSURELEFT EXPOSUREREAR EXPOSUREFRONT EXPOSURESURROUNDING EXPOSURES & OTHER OCCUPANCIESBUILDING DESCRIPTIONDESCRIPTION OF ALL OCCUPANCIES AT THIS PREMISESBLDG #:LOC #: AGENCY CUSTOMER ID:ACORD 160 (2014/12)BLKT#DESCRIPTIONCODE$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$Page 4 of 6 property ADDITIONAL COVERAGESPREMLEVELPOLLEVELFORM DATEFORM NUMBERTOTAL AMOUNT(including Base Limit)INCPREMIUMDEDUCTIBLECOVERAGEPROPER TY COVERAGES - PREMISES LEVELLOCATION IN BUILDING# PLATESAREA SQ FTLENGTH LINEAR FTGLASS TYPEINTERIORTENANTSEXTVALUEDEDGLASS$$GRO UND FLOOR GLASS$$ABOVE GROUND FLOOR GLASS$N / A$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$N / AN / AN / AN / AN / A$$N / AREJECTACCEPTN / AFOREIGNDOMESTICTERRORISMBUILDINGORDINAN CE OR LAW% REBUILDINCREASED$AGG$ORDINANCE$EXTRA EXPENSEACTUAL LOSS SUSTAINEDNO.

7 OF MONTHS$PROP DESC:CONST MATERIAL:LIMITMINE SUBSIDENCECONTENTSBUILDINGFLOOD$$$$$$$$$ $$$$$$$OUTDOOR PROPERTYPROPERTY BPP-IMPROVEMENTS& BETTERMENTS / RC / ACVBUILDING ORDINANCEINCREASED CONST COSTBUILDING ORDINANCEDEMOILITION COSTWIND EXCLUSIONADDITIONALREGULARPEAK SEASONPERSONALBUILDINGNEWLY ACQUIRED PROPERTYVALUABLE PAPERSSIGNTRANSITHAIL EXCLUSIONCONTRACTOR'S EQUIPMENTFLOATERLEASED / RENTED EQUIPMENTINSTALLATIONFUNGI / BACTERIA / MOLDFINE ARTSPREMLEVELPOLLEVEL$FORM DATEFORM NUMBERTOTAL AMOUNT(including Base Limit)INCLUDEDPREMIUMDEDUCTIBLECOVERAGEP ROPERTY COVERAGES (continued)BLDG #:LOC #: AGENCY CUSTOMER ID:ACORD 160 (2014/12)Page 5 of 6 REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)OTHER PROTECTION (Lighting, fences, watchpersons, etc.)

8 SAFE DOOR CONSTRUCTIONCRIMELABELCLASSULSMNASAFE / VAULT / RECEPTACLE MANUFACTURER'S NAMEEXTENT OF PROTECTIONSAFE / VAULTPREMISESALARM123 PARTIALCOMPLETEGRADECERT #:EXPDATE:ALARM DESCRIPTIONLOCAL GONGCNTRL STAT W/ KEYSCNTRL STAT W/O KEYSPOLICE CONNECTDEADBOLTCYLINDER DOORLOCKS? (Y/N):FREQUENCYOF DEPOSITSMONEY ONPREMISES OVERNIGHT$MAXIMUM CASHWITH MESSENGER$MAXIMUM CASHON PREMISES$SAFE / VAULTPREMISESHOLD-UPALARM TYPEDESCRIPTIONINSTALLATION DATE# UNITS owner OCCUPIED# UNITS PER FIRE DIVISION# OF FIRE DIVISIONSIS A property MANAGER EMPLOYED? (No explanation needed) DEVELOPER OR CONTRACTOR A BOARD MEMBER? (No explanation needed)Y / NEXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISESMOKE DETECTORS:NONEBATTERYWIREDCOVERAGE APPLIES TOBARE WALLSFINISHED WALLSAPARTMENTS AND CONDOMINIUMSIS THERE A PLAYGROUND ON PREMISES?

9 ALUMINUM WIRE USED? #:LOC #: AGENCY CUSTOMER ID:IS THE BUILDING UNDER CONSTRUCTION? CARRIER FOR BOILER & MACHINERY COVERAGEDATE OF LAST INSPECTIONY / NEXPLAIN ALL "YES" RESPONSES UNLESS INDICATED APPLICANT HAVE A HEATING OR PROCESSING BOILER?ANY SPECIALIZED EQUIPMENT, SUCH AS MEDICAL EQUIPMENT OR OTHER, VALUED OVER $100,000? IF "YES", GENERAL ALL EQUIPMENT INSPECTED ANNUALLY AND WELL MAINTAINED? (No explanation needed)LIFE GUARDIN GROUNDABOVE GROUNDDIVING BOARDLIMITED ACCESSIS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) FENCESLIDEACORD 160 (2014/12)THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION.

10 HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF in NJAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil in PRAny person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes thepresentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur afelony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousanddollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties.