PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO)

1 PART COMP YEARABOVE GROUND ONMASONRY FLOORABOVEGROUNDABOVE GROUND NOTON MASONRY FLOORBELOWGROUNDMANNEDSECURITYOFF PREMISESTHEFT EXCLBURGLARHSEHLDSWIMMING POOLYESDATE (MM/DD/YYYY)PHONEAGENCY(A/C, No, Ext):POLICYFAXTYPE(A/C, No):COMPANYNAIC CODE:ATTENTION:CODE:SUBCODE:AGENCY CUSTOMER IDPOL#:NAMED INSUREDACCT#:INSURED S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDEFFECTIVE DATE OF CHANGEINCEPTION DATE OF POLICYEXPIRATION DATEIF DIRECT BILL: CHANGE BILLING PLAN TO:ADDCHANGEDELETEHO FORMA. DWELLINGB. OTHERC. PERSONALD. LOSS OF USEE. PERSONALF. MEDICALSTRUCTURESPROPERTYLIABILITYPAYMEN TS$$$$$$ADDCHANGEDELETEA.

2 DWELLINGB. OTHERC. PERSONALD. RENTAL VALUEE. ADDITIONALF. PERSONALG. MEDICALSTRUCTURESPROPERTYEXPENSELIABILIT YPAYMENTS$$$$$$$FIREFIRE & ECFIRE, EC & VMMBROADSPECIALADDCHANGEDELETECOV FORMA. MOBILE HOMEB. OTHERC. PERSONALD. LOSS OF USEE. PERSONAL LIABILITYF. MEDICAL PAYMENTSSTRUCTURESPROPERTY$$$$$$FIREFIRE & ECFIRE, EC & VMMBROADSPECIALADDCHANGEDELETE#YR BUILT# ROOMSMARKET VALUESTRUCTURE TYPEUSAGE TYPE# FAM-PURCHASEILIESDATE/PRICERES$SQ FT# APTSREPLACEMENT COST$RENOVATION TYPENUMBER OFTERRPREMPROTECTDISTANCE TOPROTECTION DEVICE TYPEHEAT TYPECODEGROUPCLASSFIREUNITS INFIREHYDRANTDIVSFIRE DIVSTATIONFIRE/EC RATEFIRE DISTRICT/CODE NUMBERHOUSEKEEPING CONDITIONDATE HEATING SYSTEMNUM OF AMPSCIRCUIT BREAKERSFUSESKNOB & TUBE ORPLUMBING SYSTEMPLUMBING SYSTEMFOUNDATIONLAST SERVICED(ELEC SYST)

3 ALUMINUM WIRINGCONDITIONANY KNOWN LEAKSOIL STORAGE TANK LOCATIONWINDSTORM LOSS MITIGATIONDWELLING LOCATIONOCCUPANCYFEATURESINSPECTED?TAX CODECONDITION OFBLDG CODE# WKSOCCUPIED DAILY?WIND CLASSRATINGROOF MATERIALGRADERENTEDROOFNOIF REPLACEMENT COST APPLIES, acord 42 ATTACHED:SPRINKLERBASEMENTGARAGEBREEZEWA YTIE DOWNFOUNDATION CONSTRUCTIONMOBILEHOME:ADDCHANGEDELETEIN T #NAME AND ADDRESSLOAN NUMBERADDCHANGEDELETEINT #NAME AND ADDRESSLOAN NUMBERHOMEOWNERINLAND MARINEWATERCRAFTMOBILE HOMEDWELLING FIREUMBRELLABILL MORTGAGEEBILL APPLICANTOTHER:DIRECTAGENCYEACH OCCURRENCEEACH PERSONEACH OCCURRENCEEACH PERSONFRAMEMFG HOMEFARMMASONRYVINYL SIDINGDWELLINGTOWNHOUSEPRIMARYCOCMASONRY ALUMINUMCOMP.

4 DATE:APARTROWHOUSESECONDARYVENEERSIDINGF IRE RESCONDOCO-OPSEASONALNONEWIRINGSYSTEMSMO KETEMPPRIMARY:PLUMBINGFTMI CENTRALSECONDARY:HEATINGDIRECTROOFINGLOC ALEXTERIOR PAINTCLOSEDYESNOYESNOYESNOYESNOOPENNONEY ESNODEADBOLTUNOCCFIRE EXTINDOORSOUTDOORSWITHINAPPROVEDOWNERCIT Y LIMITSFENCEVACANTVISIBLE TOABOVEWITHINDIVINGTENANTGROUNDFIRE DISTNEIGHBORSBOARDWITHIN PROTSLIDEIN -SUBURBGROUNDSEMI-RESISTIVEYESNORESISTIV EOTHERCLASSSPECNON-SMOKERCHIMNEYSPRE-FAB PARTIALLIGHTNINGHEARTHSWOOD STOVESQ FTSQ FTSQ FTFULLPROTECTIONINSERTOVERTOPPOST & PIERONLYW/O SKIRTINGCHASSISCONTINUOUSPOST & PIERFULLNONEOTHER.

5 ONLYMASONRYWITH SKIRTINGMORTG EADDL INTMORTG EADDL INTRATING CREDITSFIREPLACESPLEASE COMPLETE REVERSE SIDEPERMISSIBLE "TYPE OF CHANGE " CODES: (A) ADD, (C) CHANGE , (D) DELETEHOMEOWNER COVERAGES/LIMITS OF LIABILITYDED (Type & Amount)DWELLING FIRE COVERAGES/LIMITS OF LIABILITYDED (Type & Amount)MOBILE HOME COVERAGES/LIMITS OF LIABILITYDED (Type & Amount)HOMEOWNER, DWELLING FIRE AND MOBILE HOME RATING/UNDERWRITINGADDITIONAL INTERESTADDITIONAL INTERESTACORD 70 (2004/05) acord CORPORATION 1992 PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO) TYPE OFPURCHASE/AMOUNT OF#PROPERTY DESCRIPTIONCHANGEAPPRAISAL DATEINSURANCEADDCHANGEDELETEOUTBOARD MOTORPORTABLEMEDICALUNINSUREDHULLTRAILER LIABILITYDEDUCTIBLEMOTOR 1 MOTOR 2 ACCESSORIESPAYMENTSBOATERS LIAB$$$$$$$$$ADDCHANGEDELETEPOLICY AMOUNTRETENTIONOTHERCOVERAGES$$PERSONALA UTOMOBILEWATERCRAFTRECREATIONAL VEHICLESBIPDPDCSLLIABILITYBICSLBIPDCSL$$ $$$$$$$$FOR COMPANY USE ONLYINSURED S SIGNATUREDATE (MM/DD/YYYY)PRODUCER S SIGNATURENATIONAL PRODUCER NUMBERUNATTENDED CAR COVERAGE (Stamps/Coins)SAFE CREDIT (Identify Property, Safe Class, Etc)BREAKAGE COVERAGE (*On Schedule)

6 BROAD FORM PAIR & SET COVERAGEACV LOSS SETTLEMENTBLANKET COVERAGENON-MOBILE ORGAN COVERAGEREPLACEMENT COST LOSS SETTLEMENTPERSONAL INLAND MARINE/SCHEDULE OF PROPERTY (Attach appraisal or bill of sale if required)WATERCRAFT COVERAGES/LIMITS OF LIABILITYPERSONAL UMBRELLA COVERAGES/LIMITS OF LIABILITYREMARKSACORD 70 (2004/05)Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance orstatement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any factmaterial thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civilpenalties.

7 (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)