BUSINESSOWNERS (BOP) XPRESS APPLICATION

1 Appalachian Underwriters: BUSINESSOWNERS (BOP) XPRESS APPLICATION Nationwide Availability (Including Florida), Wind Coverage Available if 3+ Miles From Coast, Fast Quotes, 24 Hour Turnaround Using Our Simple XPRESS App Direct Bill, Admitted, and A Rated , Best Co. Companies 10% Commission FOCUS CLASSES FOR SUCCESS! Restaurants, Habitational, and Automotive Repair/ Garage Risks are not eligible for this BOP Program. (Please Submit Acords for traditional Package Products) Healthcare Lessor's Risk No Restaurants Business Services Retail Ambulatory Surgery Centers Associations, Not for Profit Antique Stores Chiropractors Financial Institutions Authors and Playwrights Barber Shop Community Health Centers Asset Managers Carpet.

2 Rug and Beauty Salon Dental Laboratories Commodity Brokers Upholstery Cleaning Bicycle Stores Employee Health Clinics Financial Planners Charitable Foundations Book Stores Endoscopy Centers Insurance Agents Commercial Art and Bridal Stores Health Practitioners Stock Brokers Graphic Design Camera and Photographic Imaging Labs Direct Mail Services Equipment Stores Lithotripsy Centers Professional Services Lithographing Card, Stationery and Office Medical Laboratories Accountants Museums / Art Galleries Supplies Stores Medical Offices Actuarial Services Music and Art Studios Clock and Watch Stores Medical Weight Loss Clinics Advertising Agencies Pet Groomers / Pet Stores Convenience Store No GAS, Over Nurse Practitioners Architectural Consulting Photocopy, Duplicating 3,000 Sqr ft Optometrists Services Services Costume / Formal Wear Osteopaths Consultants Printers / Publishers Rental Stores Outpatient Substance Credit and Debt Ticket Agencies Craft.

3 Hobby and Artist Abuse Centers Counseling Services Supplies Stores Pain Management Centers Engineers / Architects Technology Florists Physical Therapists Interior Decorators Communications Services Grocery Stores Over 4,000 Sqr Ft Podiatrists Lawyers Management Providers Hardware Stores Psychiatrists Medical Billing Services Computer and Hearing Aid Stores Psychologists Offices Software Stores Housewares Stores Rehabilitation Centers Photographers Computer Consultants Medical, Hospital and Surgical Sleep Centers Public Relations Computer Facilities Supply Stores Smoking Clinics Real Estate Agents Management Services Nail Salon Speech Therapists Surveyors Computer Integrated Painting and Picture / Student Health Centers Tax Return Systems Design Frame Stores Vascular Access Centers Preparation Services Computer / Peripheral Party Goods Stores Telemarketing and Equipment Manufacturers Shoe Stores Institutional Research Services Computer Programming Specialty Clothing and Churches No Molestation Title Agents Computer Rental or Leasing Accessories Stores or Pastoral Liability / Veterinarians Data Communications Sporting Goods Stores

4 Counseling Videographers Vendors Trophy Stores Religious Services Wedding Consultants Internet Access Providers Wig Stores/ Shops Funeral Homes Media Duplication Pre Packaged Software Development and Design Web Site Design and Development Services Appalachian Underwriters: BUSINESSOWNERS (BOP) XPRESS APPLICATION . Email: , Fax: 866-409-3367, or Phone: 888-376-9633, ext 2111. AGENCY INFO: _____. (Contact Name) _____ (Phone) _____ AUI Producer Code (If Known) _____. General Client Information: Requested Effective Date: _____. Legal Business Name/DBA: _____. Mailing Address: _____. City, State, Zip: _____. Phone: _____ Website: _____. Type of Entity: Individual__ Corporation__ Partnership__ Other (Specify) _____.

5 FEIN/SS#: _____Classification Code (If Known Or SIC Code) _____. List and describe primary business operations: _____. _____. If LRO, type of business in building: _____. Business Start Date: _____ Years of experience in this type of business: _____. Any losses occurred in the last 5 years? _____ If yes, please provide loss runs. Liability Limits (Per / Aggregate):_____. Number of Full Time Employees: _____ Part Time Employees: _____ ____Number of Owners_____ Sales_____. Building/Location Information (Per location Repeat extra sheets for additional locations): Location address (If different from Mailing): Premises #_____ of #_____. Building #_____ of #_____. Building Limit Requested: Business Property Limit Requested: Occupancy Type (Sole or Multiple): Year Building Built: Building Construction Type: Square Footage: Protection Class: Insured Square Footage (Excluding Basement): Parking Square Feed Insured: Square Footage Leased to Others: Percentage of building occupied by Applicant: Last update: (Year / Partial or Full Update) For buildings over 25 yrs of age, does the building reflect poor Roof: _____ / P or F maintenance and/or lack of updates?

6 Must receive regularly HVAC: _____ / P or F scheduled maintenance updates (including roof, electrical, &. Electrical: _____ / P or F plumbing) to be eligible. (Y/N). Plumbing: _____ / P or F. Number of Stories: Percentage of building occupied by manufacturing tenants and/or auto repair shops with garage operations? Percent of Building Vacant: Vacant Land (Acres/Description): Do tenants and subcontractors provide proof of insurance and additional insured certificates? (Y/N). Any locations in Indiana on sites previously occupied as a gasoline During the last five years (ten in RI), has any applicant been indicted service station or underground or above ground storage tanks located for or convicted of any degree of the crime of fraud, bribery, arson, or on the premises, now or in the past?

7 (Y/N) any other arson-related crime in connection with this or any other property? (Y/N). Alarm / Fire Credits: Building WLM (Wind Loss Mitigation) Features Central Station Fire Alarm? (Y/N) AA Superior Construction (Y/N). Central Station Burglar Alarm (Y/N) Hurricane resistant Glass (Y/N). 100% Sprinklered (By ISO Standards)? (Y/N).