AGENCY CUSTOMER ID: NORTH CAROLINA GARAGE AND …

1 DATE (MM/DD/ yyyy ) NORTH CAROLINA GARAGE AND DEALERSCOVERAGES / limits SECTIONOTHER$$$$$$30 COLLISIONCOMP / OTC*SPECIFIEDPERILS*30$$$$$$$$$EXCESSPRI MARYDIRECT BASISLIABILITYLEGAL# OF AUTOSENTER THE LIMIT FOR EACH LOCATIONGARAGE KEEPERSDED PER LOSSMAXIMUMPER AUTODEDUCTIBLELOC #OTHER$DEDUCTIBLE312827242322 COLLISIONCOMP / OTC*SPECIFIEDPERILS*312827242322$$$$$$$$ $LOC #PER AUTODEDUCTIBLEDED PER LOSSMAXIMUMENTER THE LIMIT FOR EACH LOCATIONPHYSICAL DAMAGE$$BI EACH ACCIDENTEA PERBICSL2223242627 UNINSURED /UNDERINSUREDMOTORIST$$BI EACH ACCIDENTEA PERBICSL2223242627 MOTORISTUNINSURED$29282724232221 MEDICALPAYMENTSAUTO SYMBOLSCOVEREDCOVERAGESLIMITS OF LIABILITYAUTO SYMBOLSCOVEREDCOVERAGESLIMITS OF LIABILITY$PROPERTY DAMAGEUNINSUREDMOTORIST22232426272928272 4232221 LIABILITYGARAGE OPERATIONSOTHER THANAUTO ONLYUNLIMITEDLIMITED$$$AGGREGATEEA ACCAUTO ONLYDEALERS ONLY:COVERED AUTO SYMBOLS$TRANSIT LIMIT$TEMPORARY LOCATION LIMIT# HOISTSPORTATION PLATES# TRANS-REPAIRER PLATES# DEALER/PHYSICAL DAMAGE REPORTING PERIODNON-REPORTINGCOVERAGES / LIMITSAUTOMOBILEPREMISES OPERATIONSA pplies to: 1996-2010 ACORD CORPORATION.

2 All rights 138 NC (2010/02)The ACORD name and logo are registered marks of ACORDAGENCY CUSTOMER ID:AGENCYCARRIERNAIC CODEPOLICY NUMBERNAMED INSURED(S)EFFECTIVE DATEPage 1 of 2 ENDORSEMENTS / REMARKS ** Include the Fire District Name and code # if fire or COMP / OTC coverage is provided in PHYSICAL DAMAGE or GARAGE KEEPERS above COMPANY USE(32) AUTOS ON CONSIGNMENT AND DEALER AUTOS SPECIFICALLY DESCRIBED AUTOS(31) AUTOS LEFT FOR SERVICE/REPAIR/STORAGE(30) NON-OWNED AUTOS USED IN GARAGE BUS(29) HIRED AUTOS ONLY(28)(27) OWNED AUTOS SUBJECT TO UM LAW(26) OWNED AUTOS SUBJECT TO NO-FAULT(25) OWNED AUTOS OTHER THAN PRIV PASS(24) OWNED PRIVATE PASS AUTOS ONLY(23) ALL OWNED AUTOS(22) ANY AUTO(21)DATEAPPLICANT'S SIGNATURENATIONAL PRODUCER NUMBERPRODUCER'S SIGNATUREPERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, IN CONNECTION WITH THIS APPLICATION FOR INSURANCEAND SUBSEQUENT RENEWALS.

3 SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAYIN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONALINFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OURPRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT AREQUEST TO UNDERSTAND THAT THE coverage SELECTION AND LIMIT CHOICES INDICATED HERE WILL APPLY TO ALL FUTURE POLICY RENEWALS, CONTINUATIONS ANDCHANGES UNLESS I NOTIFY YOU OTHERWISE IN PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APLICATION FOR INSURANCECONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIALTHERETO, COMMITS A FRAUDULENT INSURANCE ACT.

4 WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL UNDERSTAND THAT NORTH CAROLINA LAW REQUIRES THAT MY POLICY MUST INCLUDE UNINSURED MOTORIST BODILY INJURY coverage WITH limits EQUALTO THE HIGHEST limits OF BODILY INJURY coverage ON ANY VEHICLE INSURED UNDER MY POLICY. HOWEVER, SUCH UM limits ARE NOT REQUIRED TOEXCEED $1,000,000 PER ACCIDENT, EVEN IF THE BODILY INJURY limits ARE HIGHER. I ALSO UNDERSTAND THAT MY POLICY MUST INCLUDE UNDERINSUREDMOTORIST coverage IF MY BODILY INJURY coverage IS GREATER THAN THE BODILY INJURY LIMIT REQUIRED BY LAW. I ALSO UNDERSTAND THAT I AMALLOWED TO PURCHASE GREATER OR LESSER limits AS PERMITTED BY CUSTOMER ID:Page 2 of 2 ENDORSEMENTS / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)ACORD 138 NC (2010/02)