PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO) …

1 LOC #: DATE (MM/DD/YYYY). PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO). AGENCY CARRIER NAIC CODE. NAMED INSURED. CONTACT. NAME: PHONE. (A/C, No, Ext): POLICY NUMBER. FAX. (A/C, No): E-MAIL. ADDRESS: ATTENTION: CODE: SUBCODE: ACCT#: AGENCY CUSTOMER ID: BILLING PAYMENT PLAN PAYOR. INSURED'S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGED. DIRECT BILL FULL PAY QUARTERLY INSURED MORTGAGEE. POLICY . DIRECT BILL ANNUAL BI-MONTHLY. ACCT. AGENCY BILL SEMI-ANNUAL MONTHLY PREMIUM FINANCED? (Y/N). FINANCE COMPANY: POLICY HOMEOWNER INLAND MARINE WATERCRAFT. TYPE PAYMENT METHOD. MOBILE HOME DWELLING FIRE UMBRELLA. CASH CREDIT CARD PAYROLL PRE-AUTHORIZED. EFFECTIVE DATE OF CHANGE EFFECTIVE DATE OF POLICY EXPIRATION DATE DEDUCTION DRAFT/CHECK (PAC). CHECK EFT. PERMISSIBLE "TYPE OF CHANGE " CODES: (A) ADD, (C) CHANGE , (D) DELETE. COVERAGES / LIMITS OF LIABILITY.

2 COVERAGES TYPE LIMIT PREMIUM DEDUCTIBLES TYPE TYPE AMOUNT PERCENT. CHANGE CHANGE . DWELLING $ $ BASE %. OTHER STRUCTURES $ $ WIND / HAIL %. PERSONAL PROPERTY $ $ THEFT %. LOSS ACTUAL LOSS $ $ NAMED %. OF USE SUSTAINED HURRICANE *. BLANKET * $ $ ANNUAL %. HURRICANE **. RENTAL ACTUAL LOSS $ $ %. VALUE ** SUSTAINED. ADDITIONAL EXPENSE ** $ $ %. PERSONAL LIABILITY EA OCC $ $ %. MEDICAL PAYMENTS EA PER $ $ %. * Includes Dwelling, Other Structures, PERSONAL Property, Loss of Use %. ** Dwelling Fire Only * Named Storm Percentage Deductible in North Carolina ** Not Applicable in North Carolina OPTIONAL COVERAGES - ENDORSEMENTS. COVERAGE TYPE TYPE COVERAGE INFORMATION FORM NUMBER FORM DATE PREMIUM. CHANGE . # PREMISES: $. ADDITIONAL PREMISES LOC #: TERR: $. LIABILITY EXTENSION LOC #: TERR: $. LOC #: TERR: $. # PREMISES: MED PAY (Y/N): $. ADDITIONAL.

3 RESIDENCE LOC #: TERR: # FAMILIES: MED PAY (Y/N): $. RENTED TO LOC #: TERR: # FAMILIES: MED PAY (Y/N): $. OTHERS. LOC #: TERR: # FAMILIES: MED PAY (Y/N): $. BUILDERS RISK ONLY. THEFT OF $. BUILDING MATERIALS INCLUDED. COLLAPSE DUE TO. HYDRO- STATIC INCLUDED $. PRESSURE. BUILDING ORDINANCE OR $ AGG $ INCREASED. $. LAW COVERAGE INCLUDED % REBUILD. BUSINESS PROPERTY INCLUDED $ LIMIT $. AT HOME. BUSINESS PROPERTY INCLUDED $ LIMIT $. AWAY FROM HOME. DEBRIS REMOVAL INCLUDED $ LIMIT $. % DED TERR: EARTHQUAKE RETROFIT TYPE: $. $ DED MASONRY VENEER: %. EMPLOYERS LIABILITY $ LIMIT # OF EMPLOYEES: $. ACORD 70 (2012/03) 1992-2012 ACORD CORPORATION. All rights reserved. Page 1 of 4. The ACORD name and logo are registered marks of ACORD. AGENCY CUSTOMER ID: LOC #: OPTIONAL COVERAGES - ENDORSEMENTS (continued). COVERAGE TYPE TYPE COVERAGE INFORMATION FORM NUMBER FORM DATE PREMIUM.

4 CHANGE . EQUIP BREAKDOWN. (Not applicable in NC) INC $ DED $ LIMIT $. FIRE DEPT SVC CHARGE INCLUDED $. FLOOD $ BLDG $ CONTENTS $. EXCL LIABILITY $ PROPERTY. FUNGUS AND MOLD $. EXCL PROP DAMAGE $ LIABILITY. INCLUDED # GOLF CARTS: GOLF CARTS - LIABILITY $. DESCRIPTION: GOLF CARTS - $ LIMIT $. PHYSICAL DAMAGE. IDENTITY FRAUD. INCLUDED $. EXPENSE COV. INCIDENTAL FARMING. MEDICAL PAYMENTS (Y/N): $. PERS LIAB. INCR. COV. C SPECIAL. LIABILITY LIMIT. ELECTRONIC. APPARATUS IN AND $ TOTAL $ INCREASED $. OUT OF VEHICLE. ELECTRONIC. APPARATUS IN $ TOTAL $ INCREASED $. VEHICLE. GUNS $ TOTAL $ INCREASED $. MONEY $ TOTAL $ INCREASED $. SECURITIES $ TOTAL $ INCREASED $. SILVERWARE $ TOTAL $ INCREASED $. INFLATION GUARD % INCREASE $. LOSS ASSESSMENT $ LIMIT $. CONST MATERIAL: MINE SUBSIDENCE $ LIMIT $. PROP DESC: OFFICE, PROFESSIONAL REQUIRES INCR CONTENTS TERR: MED PAY (Y/N) : PRIVATE SCHOOL, INCR CONT NOT REQUIRED STRUCT TYPE BUS/STRUCT DESC $.

5 STUDIO - RESIDENCE PREMISES $ OT. STRUCTS. OTHER STRUCTURES - STRUCT. $ LIMIT $. INDIVIDUAL STRUCTURE DESC: PLANTS, SHRUBS &. INCLUDED $ LIMIT $. TREES. REFRIGERATED FOOD. INCLUDED $ LIMIT $. PRODUCTS. REPLACEMENT COST - INCLUDED $. CONTENTS. REPLACEMENT COST - INCLUDED $. DWELLING. REPLACEMENT COST - INCLUDED % MAX $. FULL VALUE. SINK HOLE COLLAPSE INCLUDED $. UNIT-OWNERS ADDITIONS. & ALTERATIONS SPECIAL $. COVERAGE INCLUDED $ LIMIT. UNSCHEDULED JEWELRY, $ AGG $ INCREASED $. WATCHES, FURS. WATER BACKUP OF. INCLUDED $ LIMIT $. SEWERS & DRAINS. WATERCRAFT LIABILITY $ LIMIT $. WATERCRAFT. $ LIMIT $. PHYSICAL DAMAGE. WINDSTORM EXCLUSION. (Not applicable in $. Arkansas) YES. WORKERS COMP - FULL. TIME INSERVANT. (Applicable only in CA, # OF EMPLOYEES: $. MT, NV, NH, NJ, NY, ND, OH, OR, WA, WV and WY). WORKERS COMP - INCIDENTAL. (Applicable only in CA, # OF EMPLOYEES: $.)

6 MT, NV, NH, NJ, NY, ND, OH, OR, WA, WV and WY). ACORD 70 (2012/03) Page 2 of 4. AGENCY CUSTOMER ID: LOC #: OPTIONAL COVERAGES - ENDORSEMENTS (continued). COVERAGE TYPE TYPE COVERAGE INFORMATION FORM NUMBER FORM DATE PREMIUM. CHANGE . WORKERS COMP - PART TIME OUTSERVANT. (Applicable only in CA, MT, NV, NH, NJ, NY, ND, # OF EMPLOYEES: $. OH, OR, WA, WV and WY). COVERAGE DESCRIPTION $ LIMIT 1 APPLIES TO: $ LIMIT 2 APPLIES TO: DED DED TYPE: $. CODE TERR OPTIONS Y/N. RATING / UNDERWRITING ADD CHANGE DELETE. CONSTRUCTION TYPE % COURSE OF HOUSEKEEPING COND DISTANCE TO. PROTECTION DEVICE TYPE. CONSTRUCTION. MASONRY VENEER EXCELLENT SYSTEM SMOKE TEMP BURGLAR FIRE HYDRANT FIRE STATION. FIRE RESISTIVE BUILDERS RISK GOOD CENTRAL FT MI. FRAME RENOVATION AVERAGE DIRECT # FIRE DIVISIONS # UNITS FIRE DIV. MASONRY RECONSTRUCTION BELOW AVERAGE LOCAL.

7 MFG HOME USAGE TYPE DISTANCE TO TIDAL WATER DOOR LOCK SPRINKLER TERRITORY FIRE PREM GROUP. STEEL PRIMARY Miles Feet DEADBOLT PARTIAL. POURED CONCRETE SECONDARY PURCHASE PRICE SPRING FULL PERS LIAB TERR EC PREM GROUP. LOG SEASONAL $. FARM PURCHASE DATE PROT CLASS FIRE/ EC RATE. FIRE EXTINGUISHER (Y/N): SIDING %. ALUMINUM SIDING FIRE DISTRICT NAME FIRE DIST CODE. WIRING. STUCCO OCCUPANCY. COPPER. VINYL SIDING / PLASTIC OWNER ELECTRICAL SYSTEMS DATE HEATING SYSTEM LAST SERVICED: CEDAR, WOOD, ALUMINUM. SHINGLE TENANT CIRCUIT BREAKERS PRIMARY HEAT NONE. KNOB & TUBE. EIFSCB (on cinder block) UNOCCUPIED FUSES. EIFSS (on studs) VACANT LAST INSPECTED DATE NUMBER OF AMPS SECONDARY HEAT NONE. YEAR EIFS INSTALLED: SECURITY VISIBLE FROM ROAD VISIBLE TO NEIGHBORS OCCUPIED DAILY. HOMEOWNER / DWELLING FIRE RATING / UNDERWRITING ADD CHANGE DELETE. YEAR BUILT # ROOMS RESIDENCE TYPE DWELLING LOCATION RATING RENOVATIONS PART COMP YEAR.

8 DWELLING IN CITY LIMITS CLASS WIRING. MARKET VALUE # APARTMENTS APARTMENT IN FIRE DISTRICT SPECIFIC PLUMBING. $ CONDOMINIUM IN PROT SUBURB HEATING. REPLACEMENT COST # FAMILIES TOWNHOUSE FOUNDATION ROOFING. $ ROWHOUSE WIND CLASS OPEN EXTERIOR PAINT. TOTAL LIVING AREA # HOUSEHOLD RESIDENTS CO-OP RESISTIVE CLOSED PLUMBING CONDITION. SQ FT MOBILE HOME SEMI-RESISTIVE NONE EXCELLENT. BASEMENT AREA # WEEKS RENTED GOOD. SQ FT SWIMMING POOL NONE WINDSTORM AVERAGE. GARAGE AREA TAX CODE STORM A B. ABOVE GROUND SHUTTERS BELOW AVERAGE. SQ FT IN GROUND HURRICANE RESISTIVE GLASS ANY KNOWN LEAKS? (Y/N). BREEZEWAY AREA BLDG CODE GRADE APPROVED FENCE FUEL STORAGE TANK LOCATION NONE ROOF CONDITION. SQ FT DIVING BOARD INDOORS ABOVE GROUND MASONRY FLOOR EXCELLENT. FIREPLACES (Enter # or 0 INSPECTED (Y/N) SLIDE INDOORS ABOVE GROUND NO MASONRY FLOOR GOOD.)

9 For none). CHIMNEYS OUTDOORS ABOVE GROUND AVERAGE. HEARTHS RATING CREDITS LIGHTNING PROTECTION OUTDOORS BELOW GROUND BELOW AVERAGE. PRE-FAB NON-SMOKER OFF PREMISE THEFT EXCL FUEL LINE LOCATION ROOF MATERIAL. WOOD STOVE INSERT MANNED SECURITY UNDER GROUND THROUGH FOUNDATION. MOBILE HOME RATING / UNDERWRITING ADD CHANGE DELETE. NEW (Y/N) YEAR MAKE: LENGTH DOUBLEWIDE (Y/N): MOBILE HOME PARK NAME. MODEL: FT SKIRTED (Y/N): ID NUMBER WIDTH # OF BEDROOMS. DATE PARK ESTABLISHED. FT. TIE DOWN NONE PERMANENT CONNECTION TO COOKING LOCATION FOUNDATION CONSTRUCTION. # OF PERMANENT SPACES IN PARK. FULL ELECTRICITY END CONTINUOUS MASONRY. CHASSIS ONLY WATER MIDDLE POST & PIER CONSECUTIVE MONTHS. OVERTOP ONLY SEWER NONE OCCUPIED EACH YEAR: ACORD 70 (2012/03) Page 3 of 4. AGENCY CUSTOMER ID: LOC #: ADDITIONAL INTEREST ADD CHANGE DELETE. INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER.

10 ADDITIONAL INSURED LOCATION: BUILDING: LIENHOLDER VEHICLE: BOAT: LOSS PAYEE ITEM ITEM: CLASS: MORTGAGEE ITEM DESCRIPTION. TRUSTEE. REFERENCE / LOAN #: ADDITIONAL INTEREST ADD CHANGE DELETE. INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER. ADDITIONAL INSURED LOCATION: BUILDING: LIENHOLDER VEHICLE: BOAT: LOSS PAYEE ITEM ITEM: CLASS: MORTGAGEE ITEM DESCRIPTION. TRUSTEE. REFERENCE / LOAN #: PERSONAL INLAND MARINE / SCHEDULE OF PROPERTY (Attach appraisal or bill of sale if required). TYPE OF PURCHASE/ AMOUNT OF. CHANGE # PROPERTY DESCRIPTION APPRAISAL DATE INSURANCE. UNATTENDED CAR COVERAGE (Stamps/Coins) NON-MOBILE ORGAN COVERAGE ACV LOSS SETTLEMENT BREAKAGE COVERAGE (*On Schedule). BROAD FORM PAIR & SET COVERAGE SAFE CREDIT REPLACEMENT COST LOSS SETTLEMENT BLANKET COVERAGE. (Identify Property, Safe Class, Etc).