PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO) DATE …

1 Page 1 of 4 ACORD 70 (2009/06) 1992-2009 ACORD CORPORATION. All rights ACORD name and logo are registered marks of ACORDDATE (MM/DD/YYYY) PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO) PERMISSIBLE "TYPE OF CHANGE " CODES: (A) ADD, (C) CHANGE , (D) DELETEBILLINGDIRECT BILLATTENTION:ACCT#:POLICYDIRECT BILLACCTAGENCY BILLFULL PAYPAYMENT PLANANNUALSEMI-ANNUALQUARTERLYBI-MONTHLY MONTHLYPAYORINSUREDMORTGAGEEPREMIUM FINANCED? (Y/N)FINANCE COMPANY:NAMED INSUREDCASHPAYMENT METHODCHECKCREDIT CARDEFTPAYROLLPRE-AUTHORIZEDDEDUCTIONDRA FT/CHECK (PAC)(Not applicable in NC)NAIC CODECARRIERPOLICY NUMBERINSURED'S NAME AND MAILING ADDRESS (Inc ZIP+4), IF CHANGEDUMBRELLAWATERCRAFTDWELLING FIREINLAND MARINEMOBILE HOMEHOMEOWNERPOLICYTYPEE-MAILADDRESS:AGE NCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No).

2 FAXCOVERAGES / LIMITS OF LIABILITY$$$$$$$$$$$$$$$$$$PREMIUM(Dwell ing Fire Only)(Dwelling Fire Only)OTHER STRUCTURESDWELLINGBLANKET (Includes Dwelling,Other Structures, PersonalProperty, Loss of Use)LIMITCOVERAGESPERSONAL PROPERTYLOSS OF USEPERSONAL LIABILITY EA OCCMEDICAL PAYMENTS EA PERRENTAL VALUEADDITIONAL EXPENSETYPECHANGEPERCENTDEDUCTIBLES%AMOU NTBASEWIND / HAILTHEFTNAMED%%%%%%%%TYPE%TYPECHANGEHUR RICANE *ANNUALHURRICANE *LOC #:EFFECTIVE DATE OF CHANGEEFFECTIVE DATE OF POLICYEXPIRATION DATE$$$$$$MED PAY (Y/N):MED PAY (Y/N):MED PAY (Y/N):# FAMILIES:# FAMILIES:TERR:LOC #:TERR:LOC #:TERR:LOC #:TERR:LOC #:TERR:LOC #:TERR:LOC #:ADDITIONALRESIDENCERENTED TOOTHERSADDITIONAL PREMISESLIABILITY EXTENSIONPREMIUMCOVERAGE INFORMATIONCOVERAGE TYPEFORM DATEFORM NUMBER# PREMISES:# FAMILIES:MED PAY (Y/N):$$BUILDING ORDINANCE ORLAW COVERAGE$INCREASED$REBUILD$%INCLUDEDAGG$ $BUSINESS PROPERTY$$INCLUDEDINCLUDEDLIMITLIMITAT HOMEAWAY FROM HOMEBUSINESS PROPERTY$EARTHQUAKEDEDTERR:RETROFIT TYPE:MASONRY VENEER:DED$%%INCLUDEDDEBRIS REMOVAL$$LIMIT# PREMISES:TYPECHANGEBUILDERS RISK ONLYTHEFT OFINCLUDEDCOLLAPSE DUE TOINCLUDED$$BUILDING MATERIALSHYDRO- STATICPRESSUREOPTIONAL COVERAGES - ENDORSEMENTSEMPLOYERS LIABILITY$LIMIT# OF EMPLOYEES:$* Not Applicable in North CarolinaOPTIONAL COVERAGES - ENDORSEMENTS (continued)AGENCY CUSTOMER ID:LOC #:PREMIUMCOVERAGE INFORMATIONCOVERAGE TYPEFORM DATEFORM NUMBERTYPECHANGEINCR.

3 COV. C SPECIALLIABILITY LIMIT -ELECTRONIC APPARATUSIN VEHICLEINCR. COV. C SPECIALLIABILITY LIMIT -ELECTRONIC APPARATUSIN AND OUT OF VEHICLE$$$$INCREASEDINCREASED$$TOTALTOTA LFUNGUS AND MOLDPROPERTYEXCL LIABILITYEXCL PROP DAMAGE$$$LIABILITYGOLF CARTS - LIABILITY$INCLUDED# GOLF CARTS:DESCRIPTION:IDENTITY FRAUDEXPENSE COVINCLUDED$INCIDENTAL FARMINGPERS LIABMEDICAL PAYMENTS (Y/N):$GOLF CARTS -PHYSICAL DAMAGE$$LIMITOFFICE, PROFESSIONALPRIVATE SCHOOL,STUDIO -RESIDENCE PREMISESREQUIRES INCR CONTENTSINCR CONT NOT REQUIRED$OT. STRUCTSTERR:MED PAY (Y/N) :STRUCT TYPEBUS/STRUCT DESC$OTHER STRUCTURES -INDIVIDUAL STRUCTURE$LIMITSTRUCTDESC:$$REFRIGERATED FOODPRODUCTS$INCLUDEDLIMITSINK HOLE COLLAPSEINCLUDED$$PLANTS, SHRUBS &TREES$INCLUDEDLIMITUNSCHEDULED JEWELRY,WATCHES, FURS$AGGINCREASED$$WATER BACKUP OFSEWERS & DRAINS$$LIMITINCLUDED$WATERCRAFT LIABILITY$LIMITYES$WINDSTORM EXCLUSION(Not applicable inArkansas)MINE SUBSIDENCE$LIMITCONST MATERIAL:PROP DESC:$INCR.

4 COV. C SPECIALLIABILITY LIMIT -SILVERWARE$INCREASED$TOTAL$%INFLATION GUARD$INCREASELOSS ASSESSMENT$LIMIT$INCR. COV. C SPECIALLIABILITY LIMIT -SECURITIESINCR. COV. C SPECIALLIABILITY LIMIT - MONEYINCR. COV. C SPECIALLIABILITY LIMIT - GUNS$$$$$$INCREASEDINCREASEDINCREASED$$$ TOTALTOTALTOTALREPLACEMENT COST -DWELLINGREPLACEMENT COST -CONTENTSREPLACEMENT COST -FULL VALUEINCLUDEDINCLUDEDINCLUDEDMAX$$$%UNIT -OWNERS ADDITIONS& ALTERATIONS SPECIALCOVERAGE$LIMIT$INCLUDEDWATERCRAFT PHYSICAL DAMAGE$$LIMIT# OF EMPLOYEES:$# OF EMPLOYEES:$WORKERS COMP - FULLTIME INSERVANTWORKERS COMP -INCIDENTAL(Applicable only in CA,MT, NV, NH, NJ, NY, ND,OH, OR, WA, WV and WY)(Applicable only in CA,MT, NV, NH, NJ, NY, ND,OH, OR, WA, WV and WY)Page 2 of 4$FLOOD$BLDG$CONTENTSINCLUDEDFIRE DEPT SVC CHARGE$ACORD 70 (2009/06)

5 RATING / UNDERWRITING%FRAMEMASONRYMFG HOMESTEELMASONRY VENEERFIRE RESISTIVEPOURED CONCRETELOGCONSTRUCTION TYPEBELOW AVERAGEGOODEXCELLENTAVERAGEHOUSEKEEPING CONDFARMSECONDARYPRIMARYSEASONALUSAGE TYPEOCCUPANCYUNOCCUPIEDOWNERTENANTVACANT PURCHASE PRICEPURCHASE DATE$DISTANCE TOFIRE HYDRANTFTMIFIRE STATION# FIRE DIVISIONS# UNITS FIRE DIVTERRITORYFIRE PREM GROUPPERS LIAB TERREC PREM GROUPPROT CLASSFIRE/ EC RATEPROTECTION DEVICE TYPESYSTEMSMOKETEMPBURGLARCENTRALDIRECTL OCALNONEPRIMARY HEATNONESECONDARY HEATDATE HEATING SYSTEM LAST SERVICED:FULLSPRINKLERPARTIALDEADBOLTDOO R LOCKSPRINGFIRE EXTINGUISHER (Y/N):NUMBER OF AMPSCIRCUIT BREAKERSELECTRICAL SYSTEMSFUSESALUMINUMCOPPERLAST INSPECTED DATEWIRINGKNOB & TUBECOURSE OFRECONSTRUCTIONBUILDERS RISKRENOVATIONCONSTRUCTIONFeetMilesDISTA NCE TO TIDAL WATERFIRE DISTRICT NAMEFIRE DIST CODE%YEAR EIFS INSTALLED.

6 EIFSCB (on cinder block)CEDAR, WOOD,SIDINGVINYL SIDING / PLASTICALUMINUM SIDINGSTUCCOSHINGLEEIFSS (on studs)SECURITYVISIBLE FROM ROADVISIBLE TO NEIGHBORSOCCUPIED DAILYADDCHANGEDELETEWINDSTORMHURRICANE RESISTIVE GLASSSTORMABSHUTTERSOPENFOUNDATIONNONECL OSEDRESISTIVEWIND CLASSSEMI-RESISTIVERATINGSPECIFICCLASSDW ELLING LOCATIONIN PROT SUBURBIN CITY LIMITSIN FIRE DISTRICTTHROUGH FOUNDATIONUNDER GROUNDFUEL LINE LOCATIONOUTDOORS BELOW GROUNDINDOORS ABOVE GROUND MASONRY FLOOROUTDOORS ABOVE GROUNDFUEL STORAGE TANK LOCATIONNONEINDOORS ABOVE GROUND NO MASONRY FLOORNONESWIMMING POOLAPPROVED FENCEABOVE GROUNDIN GROUNDSLIDEDIVING BOARDRESIDENCE TYPECO-OPCONDOMINIUMDWELLINGAPARTMENTMOB ILE HOMEROWHOUSETOWNHOUSEWOOD STOVE INSERTHEARTHSCHIMNEYSPRE-FABFIREPLACES (Enter # or 0for none)INSPECTED (Y/N)

7 BLDG CODE GRADETAX CODE# WEEKS RENTED# HOUSEHOLD RESIDENTS# FAMILIES# APARTMENTS# ROOMSYEAR BUILTMARKET VALUE$REPLACEMENT COST$TOTAL LIVING AREASQ FTBASEMENT AREASQ FTGARAGE AREASQ FTBREEZEWAY AREASQ FTYEARCOMPPARTEXTERIOR PAINTROOFINGHEATINGPLUMBINGWIRINGRENOVAT IONSHOMEOWNER / DWELLING FIRE RATING / UNDERWRITINGPLUMBING CONDITIONAVERAGEEXCELLENTGOODBELOW AVERAGEANY KNOWN LEAKS? (Y/N)BELOW AVERAGEGOODEXCELLENTAVERAGEROOF CONDITIONROOF MATERIALOFF PREMISE THEFT EXCLMANNED SECURITYLIGHTNING PROTECTIONNON-SMOKERRATING CREDITSADDCHANGEDELETEPage 3 of 4 CONSECUTIVE MONTHSOCCUPIED EACH YEAR:# OF PERMANENT SPACES IN PARKDATE PARK ESTABLISHEDMOBILE HOME PARK NAMEWATERELECTRICITYPERMANENT CONNECTION TOSEWERFOUNDATION CONSTRUCTIONCONTINUOUS MASONRYPOST & PIERFTFTSKIRTED (Y/N):LENGTHWIDTH# OF BEDROOMSDOUBLEWIDE (Y/N):CHASSIS ONLYFULLOVERTOP ONLYTIE DOWNNONECOOKING LOCATIONNONEENDMIDDLEYEARMAKE:MODEL:ID NUMBERNEW (Y/N)MOBILE HOME RATING / UNDERWRITINGADDCHANGEDELETEOPTIONAL COVERAGES - ENDORSEMENTS (continued)PREMIUMCOVERAGE INFORMATIONCOVERAGE TYPEFORM DATEFORM NUMBERTYPECHANGEAGENCY CUSTOMER ID:LOC #:# OF EMPLOYEES.

8 $WORKERS COMP -PART TIME OUTSERVANT(Applicable only in CA,MT, NV, NH, NJ, NY, ND,OH, OR, WA, WV and WY)APPLIES TO:DEDTERRCODECOVERAGE DESCRIPTIONLIMIT 1 OPTIONSY / N$LIMIT 2 APPLIES TO:$$DED TYPE:ACORD 70 (2009/06)BOAT:VEHICLE:BUILDING:LOCATION: TRUSTEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONAL INSUREDINTEREST IN ITEM NUMBERNAME AND ADDRESSINTERESTITEM DESCRIPTIONITEMCLASS:ITEM:CERTIFICATERAN K:EVIDENCE:REFERENCE / LOAN #:ADDITIONAL INTERESTBLANKET COVERAGEBREAKAGE COVERAGE (*On Schedule)REPLACEMENT COST LOSS SETTLEMENTACV LOSS SETTLEMENTSAFE CREDIT (Identify Property, Safe Class, Etc)NON-MOBILE ORGAN COVERAGEBROAD FORM PAIR & SET COVERAGEUNATTENDED CAR COVERAGE (Stamps/Coins) PERSONAL INLAND MARINE / SCHEDULE OF PROPERTY (Attach appraisal or bill of sale if required)TYPE OFCHANGE#PROPERTY DESCRIPTIONPURCHASE/APPRAISAL DATEAMOUNT OFINSURANCEPage 4 of 4$$CSLCSL$LIABILITYCSL$$PDBIRECREATIONAL VEHICLES$$PDBIWATERCRAFT$ PERSONAL $$PDBIA UTOMOBILEPOLICY AMOUNT$RETENTION$OTHERCOVERAGESADDCHANGE DELETEPERSONAL UMBRELLA COVERAGES / LIMITS OF LIABILITY$DEDUCTIBLE$BOATERS LIABUNINSURED$PAYMENTSMEDICAL$LIABILITY$ TRAILER$ACCESSORIESPORTABLE$$MOTOR 2 MOTOR 1 OUTBOARD MOTOR$HULLADDCHANGEDELETEWATERCRAFT COVERAGES / LIMITS OF LIABILITYDATE (MM/DD/YYYY)INSURED'S SIGNATURENATIONAL PRODUCER NUMBERREMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)ADDCHANGEDELETEADDITIONAL INTERESTADDCHANGEDELETEAGENCY CUSTOMER ID:LOC #.

9 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES ANAPPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALSFOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Notapplicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES ASTATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTYOF A FELONY OF THE THIRD MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMCONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATIONCONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIMEAND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL WASHINGTON.

10 IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO ANINSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, ANDDENIAL OF INSURANCE THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURERFOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT :VEHICLE:BUILDING:LOCATION:TRUSTEELIENHO LDERMORTGAGEELOSS PAYEEADDITIONAL INSUREDINTEREST IN ITEM NUMBERNAME AND ADDRESSINTERESTITEM DESCRIPTIONITEMCLASS:ITEM:CERTIFICATERAN K:EVIDENCE:REFERENCE / LOAN #:STATE PRODUCER LICENSE NOPRODUCER'S NAME (Please Print)PRODUCER'S SIGNATURE(Required in Florida)ACORD 70 (2009/06)