Homeowner Application - Myron Steves

1 PO Box 4479, houston Texas 77210 or 3131 Eastside #600, houston Texas 77098. P. | 800:235:3817 F. | Homeowner Application Agency Information Code: Address: Name: City: State: Zip: Agency Contact: P: E: General Information Quote #: Premium: Requested Effective Date: Policy Term: 12 months New Business Renewal Rewrite of Carrier: Applicant Information Co-Applicant Information Name: Name: DOB: SSN: DOB: SSN: Occupation: Occupation: Risk Address Mailing Address if different from Risk Address Address: Address: City: State: Zip: City: State: Zip: County: If different from risk address and occupancy is primary, explain: Policy Information Endorsements, limitations, exclusions and deductibles in effect by this Application will be listed on the quote and declarations page and are agreed to by applicant(s).

2 Dwelling: Homeowners: Form A Form B. Other Structures: Windstorm, Hurricane & Hail Deductible: Personal Property: Windstorm, Hurricane & Hail Excluded Liability: All Other Peril Deductible: Med Pay: Replacement Cost for Personal Property Additional Premises Liability Med Pay Residence Glass Coverage Max 4 Locations. No Business Pursuits. Texas Locations Only. List Full Address.. Increased Limit on Jewelry/Watches/Furs: $ Location #1: Additional Insured: Relation: City: TX Zip: Occupant Non-Occupant Location #2: Section I Section II Section I & II City: TX Zip: Name: Location #3: Address: City: TX Zip: City: Location #4: State: Zip: City: TX Zip: For HOA Only: Additional Extended Coverage HO-170 MFS -170 Other: Rating Information Year Built: Type of Construction: Alarm?

3 Yes No Year of Roof: Brick, Stone or Masonry If Central Station: Roof Material: Brick Veneer Burglar Number of Roof Layers: Stucco, Cement Fiber or Asbestos Fire Year Wiring Updated: Frame Combination Burglar/Fire Year Plumbing Updated: Other: Square Feet: PPC: Number of Stories: Inside City Limits? Yes No A copy of the alarm certificate showing Occupancy: Distance to Hydrant: functions must be attached for a credit Primary Distance to Fire Station: to apply. Seasonal/Secondary Responding Fire Dept: Relative Resident: Number of Acres: HO-APP-04-16 Page 1 of 2. Filed for bankruptcy in the past three years? Yes No If yes, explain: Declined by any other carrier for credit?

4 Yes No Burglar Bars? Yes No If yes, are all burglar bars equipped with a quick release mechanism? Yes No Animals? Yes No If yes, what type: If dog, breed/mix: Swimming pool? Yes No If yes, is pool fenced? Yes No Self locking gate? Yes No Trampoline? Yes No Business Conducted on Premises? Yes No If yes, # of square feet used for business: Farming Home Office/Business Day Care - # of children: Other: Customers on premises? Yes No If yes, must provide a copy of current CGL policy. Prior Carrier Information New Purchase: Yes No If Yes, date of purchase: If no, previous carrier: Expiration Date of Current Policy: Non-renewing? Yes No If yes, reason: Loss Information 3 year history for Property and Insured required Date Description of loss Amount of loss Open Closed Repairs Completed Partial Full Partial Full Partial Full First Mortgagee Information Second Mortgagee Information Loan #: Loan #: Name: Name: Address: Address: City: State: Zip: City: State: Zip: NOTE TO AGENTS: Agents do not have binding authority.

5 Coverage is not bound until binder confirmation is issued by Myron Steves . To request binding, fax or email completed Application . Coverage cannot be backdated. Signed Application required within 7 days. If Application is mailed prior to binding, coverage will be secured day after postmark. Incomplete applications will jeopardize binding coverage. At any time, a company mandated moratorium applying to all or any part of the state(s) can affect our binding authority for new business, renewals with a lapse in coverage or increases in coverage. NOTE TO APPLICANT(S): Personal information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this Application for insurance and subsequent amendments and renewals.

6 Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to help determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection with the development of your score. You have the right to review your personal information in our files and can request correction of any inaccuracies. Any person who knowingly and with intent to defraud any insurance company or another person files an Application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

7 Endorsements, limitations, exclusion and deductibles in effect by this Application will be listed on the quote and declarations page and are agreed to by applicant(s). APPLICANT'S STATEMENT: I have read the above Application and any attachments. I declare that the information provided in them is true, complete and correct to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for which I am applying. Producer Signature Date . Applicant Signature Date . HO-APP-04-16 Page 2 of 2.