COMMERCIAL POLICY CHANGE REQUEST DATE …

1 The ACORD name and logo are registered marks of ACORDSHORT DESCRIPTION OF CHANGES / REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)POLICYTYPEPROPERTYGENERAL LIABILITYINLAND MARINEAUTOUMBRELLAWORKERS COMPTRUCKERSBUSINESS OWNERSMOTOR CARRIERSTHIS IS AN ACKNOWLEDGEMENT OF YOUR REQUEST . UPON APPROVAL, THE COMPANY'SRECORDS WILL BE ADJUSTED ACCORDINGLY, AND IF A PREMIUM ADJUSTMENT ISREQUIRED, IT WILL BE DONE AT PREMIUM AUDIT OR BY NUMBERCARRIERNAIC CODEACCOUNT NUMBERPOLICY EXPIRATION DATEPOLICY INCEPTION DATEEFFECTIVE date OF CHANGEATTENTIONINSURED'S NAME AND MAILING ADDRESS, IF CHANGED (INC ZIP+4)NAMED INSUREDFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAIL 1991-2012 ACORD CORPORATION. All rights 1 of 2 ACORD 175 (2012/04) COMMERCIAL POLICY CHANGE REQUESTDATE (MM/DD/YYYY)$COST NEWSYMCOLLOTC SYMCOMP /$TOTAL PREM:OTCFGREIMBRENTCOLLCOMP/LSPFTWFTFC OF LSPEC& LABORTOWINGMOTORUNDRINSMOTORUNINSMED PAYFAULTADD'L NO-FAULTNO-LIABCOVERAGESCHECKFOR HIRESERVICERETAILCOMM'LFARMPLEASUREUSE15 MILES +< 15 MILESWORK / SCHOOLDRIVE TOZIPSTATECOUNTYCITYSTREET (Required in KY)GARAGINGADDRESSSTATELICTERRGVW / GCWCLASSSICFACTORSEAT CPRADIUSFARTHEST TERMINALNET VEHDR/CR:OTCCOLL$$C OF LSPECCOMP/$ST AMTAAACVDEDUCTIBLESSYM / :TYPE:BODYMODEL:MAKE:YEARVEH #PPSPECCOMLVEHICLE TYPEADDCHANGEDELETEPOLICY LIMIT(S) CHANGED$LIABILITY$NO FAULT$ADD'L NO FAULT$UNINSURED MOTORISTSAUTO-VEHICLE DESCRIPTION / LIMITSMEDICAL PAYMENTS$$UNDERINSURED MOTORISTS$COST NEWSYMCOLLOTC SYMCOMP /$TOTAL PREM.

2 OTCFGREIMBRENTCOLLCOMP/LSPFTWFTFC OF LSPEC& LABORTOWINGMOTORUNDRINSMOTORUNINSMED PAYFAULTADD'L NO-FAULTNO-LIABCOVERAGESCHECKFOR HIRESERVICERETAILCOMM'LFARMPLEASUREUSE15 MILES +< 15 MILESWORK / SCHOOLDRIVE TOZIPSTATECOUNTYCITYSTREET (Required in KY)GARAGINGADDRESSSTATELICTERRGVW / GCWCLASSSICFACTORSEAT CPRADIUSFARTHEST TERMINALNET VEHDR/CR:OTCCOLL$$C OF LSPECCOMP/$ST AMTAAACVDEDUCTIBLESSYM / :TYPE:BODYMODEL:MAKE:YEARVEH #PPSPECCOMLVEHICLE TYPEADDCHANGEDELETEPOLICY LIMIT(S) CHANGED$LIABILITY$NO FAULT$ADD'L NO FAULT$UNINSURED MOTORISTSAUTO-VEHICLE DESCRIPTION / LIMITSMEDICAL PAYMENTS$$UNDERINSURED MOTORISTSPREMISES INFORMATIONPART OCCUPIEDYR BUILTINTERESTCITY LIMITSSTREET, CITY, COUNTY, STATE, ZIP+4 BLD #LOC #ADDCHANGEDELETEINSIDEOUTSIDEOWNERTENANT BLD #LOC #NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS BY PREMISE(S)ADDCHANGEDELETE* MARITAL STATUS / CIVIL UNION (if applicable)CITY, STATE AND ZIP CODENAMEDRIVER INFORMATION (List drivers who frequently use own vehicles)ADDCHANGEDELETEDOCUSE%VEH #USEHIREDATELICSTATESOCIAL SECURITY NUMBERDRIVERS LICENSE NUMBER/LICYEAREXPYRSDATE OF BIRTHSTAT* MARSEX# 175 (2012/04)ADDCHANGEDELETEADDITIONAL INTERESTITEM DESCRIPTIONITEM:ITEM CLASS:BOAT:BUILDING:VEHICLE:MORTGAGEECER TIFICATEAS LESSORINSUREDEVIDENCE:RANK.

3 NAME AND ADDRESSREGISTRANTOWNERINTERESTINTEREST IN ITEM NUMBERADDITIONALLOSS PAYEELIENHOLDEREMPLOYEEAIRPORT:REFERENCE / LOAN #:LOCATION:AGENCY CUSTOMER ID:TYPE OFCHANGESTATELOCCLASS CODEDESCRCODECATEGORIES, DUTIES, CLASSIFICATIONS# OFEMPLOYEESESTIMATEDANNUALREMUNERATIONFU LLPARTTIMETIMEWORKERS COMPENSATION RATING INFORMATIONPage 2 of 2$EMPLOYEE BENEFITS$$EACH OCCURRENCE$PERSONAL & ADVERTISING INJURY$PRODUCTS & COMPLETED OPERATIONS AGGREGATE$GENERAL AGGREGATE$MEDICAL EXPENSE (Any one person)GENERAL LIABILITY - LIMITSCHANGE$DAMAGE TO RENTED PREMISESGROSS SALES - PER $1,000/SALESPAYROLL - PER $1,000/PAYAREA - PER 1,000/SQ FTTOTAL COST - PER $1,000/COSTADMISSIONS - PER 1,000/ADMUNIT - PER UNITOTHER(S)(P)(A)(C)(M)(U)(T)PREMIUM BASIS CODESLOC#CLASSIFICATIONCLASSCODEPREMIUMB ASISTERREXPOSUREHAZ#CHANGETYPE OFGENERAL LIABILITY - SCHEDULE OF HAZARDSCHANGEUMBRELLA(DESCRIBE)OTHER$LIM IT OF LIABILITY$RETAINED LIMIT/ Chemical Systems)

4 2 PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CODISTANCE TOHYDRANTFIRE STATFTMICONSTRUCTION TYPEFIRE DISTRICT / CODE NUMBERTAX CODEROOFTYPEY / NGRADEBLDG CODEINSPECTED?BUILDING IMPROVEMENTSWIRING, YR:ROOFING, YR:PLUMBING, YR:HEATING, YR:OTHER:FIRE ALARM MANUFACTURERLOCAL GONGCENTRAL STATIONCLOCK HOURLY# GUARDS/WATCHMENBURGLAR ALARM INSTALLED AND SERVICED BYEXPIRATION DATECERTIFICATE #BURGLAR ALARM TYPEEXTENTGRADEWITH KEYSCENTRAL STATIONREAR EXPOSURE & DISTANCELEFT EXPOSURE & DISTANCERIGHT EXPOSURE & DISTANCEOTHER OCCUPANCIESTOTAL AREAYR BUILT# BASM'TS# STORIESPROT CLADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION (Attach ACORD 101, Additional Remarks Schedule, if more space is required)FORMS AND CONDITIONS TO APPLYDEDUCTIBLEGUARD %INFLATIONCAUSES OF LOSSVALUATIONCOINS %AMOUNTSUBJECT OF INSURANCEBUILDING #:PREMISES #:PROPERTY / INLAND MARINE - PREMISES INFORMATIONADDCHANGEDELETE$$INSURANCEAMO UNT OFNEW/USEDPURCHASEDDATEID #/SERIAL #DESCRIPTION (TYPE, MANUFACTURER, MODEL, CAPACITY, ETC)YEARMODEL#INLAND MARINE - SCHEDULED EQUIPMENT% COINSURANCE:ADDCHANGEDELETENATIONAL PRODUCER NUMBER(Required in Florida)PRODUCER'S SIGNATUREDATEINSURED'S SIGNATUREPRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NOSIGNATURE (Any deletion or reduction in coverage requires the Insured's signature))