DATE APPLICATION FOR BASIC PROPERTY & …

1 77 HARTLAND STREET BOX 280200, EAST HARTFORD, CT 06128-0200 TEL (860) 528-9546, FAX (860) 282-0070 CONNECTICUT FAIR PLANTHIS IS NOT A BINDER OF INSURANCECONNECTICUT FAIR PLANAPPLICATION FOR BASIC PROPERTY & LIABILITY INSURANCEDATEFAIR PLAN USEUND INITIALS:DATE:APPROVEDREJECTEDQUOTATION #3. TAX ID # (if Corporation)2. MAILING ADDRESS (INCLUDE ZIP CODE)1. APPLICANT (NAME AS IT SHOULD APPEAR ON POLICY):PLEASE COMPLETE EVERY ITEM WITH ANSWERS TYPEWRITTEN OR PRINTED LEGIBLY IN INK. IF AN ITEM IS NOT APPLICABLE, WRITE 'S SIGNATURE IS REQUIRED ON PAGE INSTRUCTIONS ON PAGES 3 AND 4 PRODUCER E-MAIL ADDRESSPRODUCER NAMEPRODUCER FAX (A/C, NO)PRODUCER PHONE (A/C, NO, EXT)PRODUCER ADDRESSI HEREBY CERTIFY THAT I AM A LICENSED PRODUCER OF CONNECTICUT.

2 IN THE EVENT A POLICY IS ISSUED AND THEN CANCELLEDOR INSURANCE THEREUNDER TERMINATED, OR A CHANGE IS MADE RESULTING IN A RETURN PREMIUM DUE, I AGREE TO RETURN MYPROPORTIONATE SHARE OF THE COMMISSION OF SUCH RETURN OF PRODUCER OF RECORD:GIVE US YOUR TAX ID NUMBER ON A SEPARATE PIECE OF PAPERLOCATION OF PROPERTY TO BE INSURED, WITH ZIP CODE (ATTACH SPECIFIC DIRECTIONS IF THERE IS NO STREET NUMBER) TELEPHONE NUMBER FOR INSPECTION:WORK:HOME:CELL:WHAT IS THE APPLICANT'S INSURABLE INTEREST IN THEPROPERTY?

3 (EXPLAIN):(d) DATE OFPRESENT OR PRIOR COVERAGE:(a)(b)AMOUNT OF BUILDING COVERAGE:$INSURANCE COMPANY:REASON FOR NON-RENEWAL OR CANCELLATION:(c)APPROXIMATEYEAR BUILT:OTHERFRAMEBRICKCONSTRUCTION OF VACANT OR UNOCCUPIED, FORM #7, VACANCY QUESTIONNAIREMUST BE ATTACHEDUNOCCUPIEDESTATEOCCUPIED12. THE PROPERTY IS:VACANTRENOVATION13. NUMBER OF STORIESYESNOYESNOSEASONAL?ROWHOUSEOR CONDO? YOU HAVE FLOOD INSURANCE? :$DATE BUILDING PURCHASED:9. ARE UTILITIES (HEAT, WATER, ELECTRICITY) IN SERVICE?YESNOHAVE YOU FAILED TO PAY PROPERTY TAXES FORYESNOTWO (2) YEARS OR MORE?

4 IF YES, BUILDING BEEN CLASSIFIED AS UNINHABITABLE OR STRUCTURALLYUNSAFE, BY ANY AUTHORITY? IF YES, ANY PERSON WITH A FINANCIAL INTEREST IN THIS PROPERTYBEEN CONVICTED OF FRAUD OR INCENDIARISM? IF YES, FIRE PROTECTION/SMOKE DETECTION DEVICES, REQUIRED BY LAW,INSTALLED AND WORKABLE? IF NO, EXPLAIN:Page 1 of 4 2001-2015 ACORD CORPORATION. All rights 66 CT (2015/02)IF "NO", EXPLAIN:REMARKSHAVE YOU HAD ANY LOSSES TO THISPROPERTY WITHIN THE PAST THREEYEARS? IF YES, COMPLETE THE DATE, CAUSE, AMOUNT PAID ANDCURRENT STATE OF REPAIRS OF EACH LOSS:DESCRIBE LIABILITY LOSS IN DETAIL:YESNOMILESFEETFIRE DEPARTMENT WITHIN:19.

5 HYDRANT WITHIN:20. IF TENANT OCCUPIED, MONTHLY RENTAL INCOME:$(c) NAME AND COMPLETE ADDRESS OF LOSS PAYEE(S):ARE PAYMENTS DELINQUENT? IF YES, EXPLAIN:$YESNO(b) AMOUNT OF OUTSTANDING MORTGAGE(S):21. (a) NAME AND COMPLETE ADDRESS OF MORTGAGEE(S) REPLACEMENT COSTLAND$$$ESTIMATED MARKET VALUE:24. APPLICATION IS MADE FOR THE FOLLOWING INSURANCE WHICH IS LIMITED TO THE BUILDINGS AND CONTENTS DESCRIBED.(COVERAGE REQUESTED SHOULD BE FOR ACTUAL CASH VALUE, NOT REPLACEMENT COST)VANDALISM & MALICIOUS MISCHIEF(WIND, HAIL, SMOKE, AIRCRAFT OR VEHICLES, RIOT OR CIVILCOMMOTION, SINKHOLE COLLAPSE, VOLCANIC ACTION)CHECK PERILS DESIRED:FIRE, LIGHTNING,EXPLOSIONEXTENDED COVERAGEVACANT(1 - 4 FAMILIES)NUMBER OF FAMILIESOWNEROCCUPIEDTENANTOCCUPIEDHABIT ATIONAL PROPERTYCOINSURANCE: NONE AVAILABLE$(IN ADDITION TO THE 10% AUTOMATIC COVERAGE)$$OTHER STRUCTURESCONTENTSBUILDINGAMOUNT OF COVERAGE DESIRED.

6 (VACANT / UNOCCUPIED = CLOSEST TO 5%, WITH $1,000 MIN and $10,000 MAX)$2,500$1,000$500$250 DEDUCTIBLE:VACANT /UNOCCUPIEDLIABILITYFOR 1 - 3 FAMILY DWELLINGS ONLYAMOUNT DESIRED:$25,000$50,000$100,000$300,000(F IRE, LIGHTNING, EXPLOSION)SPRINKLER LEAKAGEVANDALISM & MALICIOUS MISCHIEF(WIND OR HAIL, SMOKE, AIRCRAFT ORVEHICLES, RIOT OR CIVIL COMMOTION,SINKHOLE COLLAPSE, VOLCANIC ACTION)GROUP IICHECK PERILS DESIRED:GROUP ICOMMERCIAL PROPERTYAMOUNT OF COVERAGE DESIRED:BUILDINGCONTENTSOTHER STRUCTURES$$(NO AUTOMATIC EXTENSIONS)$EXACT OCCUPANCY:DEDUCTIBLE:$5,000$1,000$500$25 ,000$10,000$2,500$50,000 VACANT / UNOCCUPIED$75,000 FLAT / NO COINSURANCE80%90%COINSURANCEPage 2 of THERE ANY UNREPAIRED DAMAGE ON THE PROPERTY ?

7 IF "YES", EXPLAIN:YESNO$7,500$5,000$10,000(VACANT / UNOCCUPIED = CLOSEST TO 5%, WITH $1,000 MIN and $75,000 MAX)ACORD 66 CT (2015/02)NOTICE TO APPLICANT: THE PRODUCER LISTED IN THIS APPLICATION IS NOT A REPRESENTATIVE OR AN AGENT OF THECONNECTICUT FAIR PLAN. HE IS YOUR REPRESENTATIVE AND AGENT. ACCORDINGLY, THE DELIVERY OF ANY NOTICE ORINFORMATION REQUIRED FROM YOU BY THIS APPLICATION , OR ANY POLICY THAT MAY BE SUBSEQUENTLY ISSUED BYTHE CONNECTICUT FAIR PLAN, IF GIVEN TO YOUR AGENT, WILL NOT CONSTITUTE DELIVERY TO THE CONNECTICUT FAIRPLAN UNLESS SUCH NOTICE OR INFORMATION IS IN FACT DELIVERED TO THE CONNECTICUT FAIR PLAN.

8 THECONNECTICUT FAIR PLAN WILL NOT BE RESPONSIBLE FOR THE FAILURE OF YOUR AGENT TO DELIVER ANY NOTICE OF APPLICANTDATE:THERE IS A $25 CHARGE FOR ANY CHECK RETURNED FROM THE BANKIF APPLICANT IS A PARTNERSHIP, COMPANY OR CORPORATION, A CORPORATE QUESTIONNAIRE MUST ALSO BE COMPLETED ANDSIGNED BY AN OFFICIAL OF THE FIRM, PRINTING NAME AND TITLE BELOW AS WELL AS CERTIFICATION OF APPLICANT IS AN INDIVIDUAL, PERSONAL SIGNATURE, NOT THAT OF AN AGENT OR BROKER, IS REQUIREDPROVISIONAL PREVENT LAPSES OF INSURANCE COVERAGE FOR RISKS ELIGIBLE UNDER THE PROGRAM BEFORE COVERAGE HAS BEEN MADEAVAILABLE OR DECLINED.

9 THE INSURANCE REQUESTED, SUBJECT TO ALL PROVISIONS OF THIS PROGRAM, WILL BEAUTOMATICALLY EFFECTIVE ON THE TWENTY-FIRST DAY FOLLOWING THE DATE THE APPLICATION WAS RECEIVED OR SUCH LATERDATE REQUESTED BY THE INSURED ON THE APPLICATION NO FAULT OF THE APPLICANT, COVERAGE HAS NOT BEEN EITHER OFFERED OR DENIED WITHIN TWENTYCALENDAR DAYS AFTER THE DATE THE REQUEST FOR INSPECTION WAS RECEIVED APPLICANT, AT ANY TIME PRIOR TO THE RECEIPT OF AN INSPECTION REPORT INDICATING THAT THE PROPERTY ISUNINSURABLE, PAYS THE ESTIMATED ANNUAL RATES SHALL BE USED IN DEVELOPING THE ESTIMATED ANNUAL PREMIUM WHICH SHALL BE SUBJECT TO ANAPPROPRIATE PREMIUM ADJUSTMENT, BASED ON THE INSPECTION OF THE APPLICATION IS FOR AN ACTUAL CASH VALUE POLICY.

10 WE DO NOT PROVIDE REPLACEMENT COST FOR BUILDINGS OR SIGNING THIS APPLICATION I (WE) CERTIFY THAT I (WE) HAVE AN INSURABLE INTEREST IN THE PROPERTY , AND THAT ALLINFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY (OUR) KNOWLEDGE AND BELIEF. MISREPRESENTATIONCOULD VOID THE OF APPLICANT FOR INSURANCEAPPLICANT MUST SIGN AND DATE THIS APPLICATIONTHIS REQUEST IS MADE WITH THE UNDERSTANDING THAT AN INSPECTION MAY BE MADE ON THIS PROPERTY . I (WE) UNDERSTAND THATTHIS REQUEST IN NO WAY BINDS THE FAIR PLAN TO AFFORD INSURANCE ON THE DESCRIBED PROPERTY .