DWELLING FIRE APPLICATION DATE (MM/DD/YYYY)

1 CIVIL UNION (if applicable)MARITAL STATUS * /ACORD 84 (2013/09)LOC #:PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)FINANCE COMPANYY / NPREMIUM FINANCED?MORTGAGEEINSUREDPAYORPRE-AUTHOR IZED DRAFT/CHECK (PAC)PAYROLL DEDUCTIONEFTCREDIT CARDCHECKCASHPAYMENT METHODMONTHLYBI-MONTHLYQUARTERLYSEMI-ANN UALANNUALFULL PAYPAYMENT PLANMAIL POLICY TO:AGENTINSUREDAGENCY BILLDIRECT BILL - ACCTDIRECT BILL - POLICYBILLINGBILLING ACCOUNT #:EST TOTAL PREMIUM:DEPOSIT AMOUNT:$$FORM NAMEFORMS AND ENDORSEMENTS (ACORD 829, Forms and Endorsements Schedule, may be attached if more space is required)

2 LOC #FORM NUMBEREDITION DATECOPYRIGHT OWNER CODESUSTAINEDACTUAL LOSS* Named Storm Percentage Deductible in North Carolina$%$%DEDUCTIBLES$%INCLUDEDSUSTAIN EDACTUAL LOSSTOTAL LOCATION PREMIUM$FIREFIRE & ECFIRE, EC & VMMBROADSPECIAL$$$% MAXHURRICANE**HURRICANE*$$$$AMOUNTTYPE%% %%PERCENT$$$$DEDUCTIBLEAMOUNTLIMITINCLUD EDINCLUDEDINCLUDEDOPTIONREPL COST - CONTENTSREPL COST - DWELLINGREPL COST - FULL VALUECOVERAGE* Includes DWELLING , Other Structures, Personal Property, Loss of Use** Not Applicable in North CarolinaTYPE%%%ANNUALNAMEDTHEFTWIND / HAILBASEPREMIUM%DEDUCTIBLEPERCENTADDITIO NAL EXPENSERENTAL VALUEMEDICAL PAYMENTS EA PERPERSONAL LIABILITY EA OCCLOSS OF USEPERSONAL PROPERTYCOVERAGELIMITBLANKET *DWELLINGOTHER STRUCTURESPREMIUM$$$$$$$$$$$$$$$$$$COVER AGES / LIMITS OF LIABILITYPage 1 of 5 date OF BIRTHSOCIAL SECURITY #* This field may not be utilized for policyholders applying for residential property insurance in WITH PREVIOUS EMPLOYER:YEARS IN CURRENT OCCUPATION:YEARS WITH CURRENT EMPLOYER:Check if same as mailing addressDWELLING LOCATIONDATE AT MAILING ADDRESS.

3 PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSAPPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)YEARS AT PREVIOUS ADDRESS (if less than three years):PREVIOUS ADDRESSSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:APPLICANT'S NAME (First, Middle, Last)APPLICANT'S MAILING ADDRESSAPPLICANT INFORMATIONHOW LONG HAVE YOU KNOWN THE APPLICANTDATE AGENT LAST INSPECTED PROPERTYNAMED INSURED(S)POLICY NUMBEREFFECTIVE DATEEXPIRATION DATECARRIERNAIC CODEPLANFACILITY CODEFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILDATE (MM/DD/YYYY) DWELLING fire APPLICATIONThe ACORD name and logo are registered marks of ACORD 1981-2013 ACORD CORPORATION.

4 All rights 84 (2013/09)TYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DESCRIPTIONY / N:CODETERR:$$$$PREMIUMTYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DEDUCTIBLEDESCRIPTIO NY / N:OPTSLIMITCOVERAGE TYPECODETERR:APPL TO$$$$PREMIUMTYPE:DESCRIPTIONY / N:CODETERR:$$$$TYPE:DEDUCTIBLEDESCRIPTIO NY / N:OPTSLIMITCOVERAGE TYPECODETERR:APPL TO$$$$$ fire DEPARTMENTSERVICE CHARGEINCLUDED(Not applicable in Arkansas)YESWINDSTORM EXCL$LIMIT$INCLUDED$WATER BACKUP OFSEWERS & DRAINSLIMIT$INCLUDEDUNIT-OWNERSADDITIONS &ALTERATIONSSPECIAL COVERAGE$INCREASEINFLATION GUARD%$$$LOSS ASSESSMENTLIMIT$LIMITPROP DESC:CONST MATERIAL:MINE SUBSIDENCE$$$$LIMITDEBRIS REMOVALINCLUDED%% DED$DEDMAS VENEER:RETROFIT TYPE:TERR.

5 EARTHQUAKELIMIT$LIMIT$$$$AGGINCLUDED%REB UILD$INCR$BUILDING ORD ORLAW COVERAGEINCLUDEDCOLLAPSE DUE TOHYDRO-STATICPRESSUREINCLUDEDTHEFT BLDGMATERIALSBUILDERS RISKPREMIUMCOVERAGE TYPECOVERAGE INFORMATIONPREMIUMOPTIONAL COVERAGES - ENDORSEMENTSCOVERAGE TYPECOVERAGE INFORMATIONLOC #:AGENCY CUSTOMER ID:NEIGHBORSROADROOF MATERIALROOF CONDITIONAVERAGEEXCELLENTGOODBELOW AVGANY KNOWN LEAKS? (Y/N)BELOW AVGGOODEXCELLENTAVERAGEPLUMBING CONDITIONTOWNHOUSEROWHOUSEAPARTMENTDWELL INGCONDOMINIUMCO-OPRESIDENCE TYPECONSTRUCTION TYPEMASONRY VENEERMASONRYFRAME%OCCUPIED DAILYVISIBLE TOVISIBLE FROMSECURITYEIFSS (on studs)SHINGLESTUCCOALUMINUM SIDINGVINYL SIDING / PLASTICSIDINGCEDAR, WOOD,EIFSCB (on cinder block)YEAR EIFS INSTALLED.

6 % fire DIST CODEFIRE DISTRICT NAMEDISTANCE TO TIDAL WATERM ilesFeetCOURSE OF CONSTRUCTIONRENOVATIONBUILDERS RISKRECONSTRUCTIONKNOB & TUBEWIRINGLAST INSPECTED DATECOPPERALUMINUMFUSESELECTRICAL SYSTEMSCIRCUIT BREAKERSNUMBER OF AMPSSPRINGDOOR LOCKDEADBOLTPARTIALSPRINKLERFULLDATE HEATING SYSTEM LAST SERVICED:SECONDARY HEATNONEPRIMARY HEATNONELOCALDIRECTCENTRALBURGTEMPSMOKES YSTEMPROTECTION DEVICE TYPEY / NFIRE EXTINGUISHERPROT CLASSPERS LIAB TERRTERRITORY# UNITS fire DIV# fire DIVISIONSFIRE STATIONMIFTFIRE HYDRANTDISTANCE TO$PURCHASE DATEPURCHASE PRICEVACANTTENANTOWNERUNOCCUPIEDOCCUPANC YUSAGE TYPESEASONALPRIMARYSECONDARYFARMHOUSEKEE PING CONDITIONAVERAGEEXCELLENTGOODBELOW AVGRATING / UNDERWRITINGSEMI-RESISTIVEWIND CLASSRESISTIVESTORM SHUTTERSBAHURRICANE RESISTIVE GLASSWINDSTORMINDOORS ABOVE GROUND NO MASONRY FLOORNONEFUEL STORAGE TANK LOCATIONOUTDOORS ABOVE GROUNDINDOORS ABOVE GROUND MASONRY FLOOROUTDOORS BELOW GROUNDFUEL

7 LINE LOCATIONUNDER GROUNDTHROUGH FOUNDATIONDIVING BOARDSLIDEIN GROUNDABOVE GROUNDAPPROVED FENCESWIMMING POOLNONERENOVATIONSWIRINGPLUMBINGHEATING ROOFINGEXTERIOR PAINTPARTCOMPYEARCLASSSPECIFICRATINGCLOS EDNONEFOUNDATIONOPENIN fire DISTRICTIN CITY LIMITSIN PROT SUBURBDWELLING LOCATIONRATING CREDITSNON-SMOKERLIGHTNING PROTECTIONMANNED SECURITYOFF PREMISE THEFT EXCLRESIDENTS# ROOMS# APARTMENTS# FAMILIES# HOUSEHOLD# WEEKS RENTEDTAX CODEBLDG CODE GRADEINSPECTED (Y/N):FIREPLACES (Enter # or 0 for none)PRE-FABCHIMNEYSHEARTHSWOOD STOVE INSERTSQ FTBREEZEWAY AREASQ FTGARAGE AREASQ FTBASEMENT AREASQ FTTOTAL LIVING AREA$REPLACEMENT COST$MARKET VALUEYEAR BUILTPage 2 of 5 ACORD 84 (2013/09)EXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISEY / OTHER insurance WITH THIS COMPANY?

8 (List policy numbers)POLICY NUMBERPOLICY NUMBERLINE OF BUSINESSLINE OF APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS? APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS? ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS?(Missouri Applicants - Do not answer this question)GENERAL INFORMATIONANY OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION , OWNED, OCCUPIED OR RENTED? insurance BEEN TRANSFERRED WITHIN AGENCY? THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREEOF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?

9 (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)LOC #:AGENCY CUSTOMER ID:Page 3 of 5%Y / NEXCLINCLY / Nsq. 'S NAME:IS THE NAMED INSURED THE OWNER OF THE PROPERTY? (If "NO", provide the name of the owner) THERE AN APPROVED CARBON MONOXIDE ALARM IN OPERATING CONDITION WITHIN THE MANDATED NUMBER OF FEET OF EVERYROOM USED FOR SLEEPING PURPOSES? (IL - 15 FT) (no explanation needed)14.$COST OF PROJECTOCC DURING RENMATERIALS UNATTACHEDSTRUC CHANGESCOMP DATESTART DATEADD LEVELADDITIONEXTINTNAME OF THE RESIDENCE IN A GATED COMMUNITY?

10 CLEANUP/SUBLIMIT:LIMIT: insurance A FUEL TANK IS ON PREMISES, HAS OTHER insurance BEEN OBTAINED FOR THE TANK?(If "YES", provide the name of the insurance company, the applicable limit and the cleanup sublimit) LEAD PAINT? BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR?a. IF "YES", IS THERE A SAFETY NET? (no explanation needed)ORIGINAL OCCUPANCY:WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? USED FOR:# OF ACRES:IS PROPERTY SITUATED ON MORE THAN ONE ACRE? UNCORRECTED fire OR BUILDING CODE VIOLATIONS?IS THE DWELLING FOR SALE? (no explanation needed) PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY?