PROPERTY LOSS NOTICE DATE (MM/DD/YYYY)

1 CIVIL UNION (if applicable)MARITAL STATUS /FEIN (if applicable)CIVIL UNION (if applicable)MARITAL STATUS /PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:NAME OF INSURED (First, Middle, Last)INSURED'S MAILING ADDRESSFEIN (if applicable) date OF BIRTHINSUREDPHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:NAME OF SPOUSE (First, Middle, Last) (if applicable)SPOUSE'S MAILING ADDRESS (if applicable) date OF BIRTHFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILDESCRIBE LOCATION OF loss IF NOT AT SPECIFIC STREET ADDRESS:REPORTED BYREPORTED TOREPORT NUMBERLOSSPOLICE OR FIRE DEPARTMENT CONTACTEDCOUNTRY:CITY, STATE, ZIP:STREET:LOCATION OF LOSSPROBABLE AMOUNT ENTIRE LOSSKIND OFLOSSWINDFLOODHAILLIGHTNINGTHEFTFIREDES CRIPTION OF loss & DAMAGE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)NAIC CODECARRIERPOLICY NUMBERFLOOD POLICYNAIC CODECARRIERPOLICY NUMBERWIND POLICYNAIC CODECARRIERPOLICY NUMBERINSURED LOCATION CODEDATE OF loss AND TIMEAMPMPROPERTY / HOME POLICYPROPERTY loss NOTICEDATE (MM/DD/ yyyy )PHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:NAME OF CONTACT (First, Middle, Last)CONTACT'S MAILING ADDRESSCONTACTCONTACT INSUREDWHEN TO CONTACT 1988-2016 ACORD CORPORATION.

2 All rights 1 of 3 The ACORD name and logo are registered marks of ACORDLINE OF BUSINESSACORD 1 (2016/10)ACORDs provided by Forms Boss. ; (c) Impressive Publishing 800-208-1977 Applicable in Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement inprison, or any combination (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)AGENCY CUSTOMER ID:Page 2 of 3 Applicable in Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claimcontaining false, incomplete, or misleading information may be prosecuted under state in Arizona.

3 For your protection Arizona law requires the following statement to appear onthis form. Any person who knowingly presents a false or fraudulent claim for payment of a loss issubject to criminal and civil in Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in in California: For your protection California law requires the following to appear on this form. Any person who knowinglypresents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance companyfor the purpose of defrauding or attempting to defraud the company.

4 Penalties may include imprisonment, fines, denial of insurance andcivil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading factsor information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regardto a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department ofRegulatory in Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claimcontaining any false, incomplete or misleading information is guilty of a in the District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purposeof defrauding the insurer or any other person.

5 Penalties include imprisonment and/or fines. In addition, an insurer may deny insurancebenefits if false information materially related to a claim was provided by the in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claimcontaining any false, incomplete, or misleading information is guilty of a felony of the third in Hawaii: Any person who intentionally or knowingly misrepresents or conceals material facts, opinions, intention, or law toobtain or attempt to obtain coverage, benefits, recovery, or compensation commits the offense of insurance fraud which is a crimepunishable by fines or imprisonment or in Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statementcontaining any false, incomplete or misleading information is guilty of a in Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,incomplete, or misleading information commits a in Kansas.

6 Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares withknowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic,electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for theissuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant toan insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning anyfact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulentinsurance 1 (2016/10)Applicable in Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, which is a CUSTOMER ID:Page 3 of 3 Applicable in Louisiana.

7 Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in in Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance in Michigan: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in in Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a in Nevada: Pursuant to NRS , any person who knowingly and willfully files a statement of claim that contains anyfalse, incomplete or misleading information concerning a material fact is guilty of a category D in Maryland.

8 Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit orwho knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines andconfinement in in New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statementof claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud asprovided in RSA 638 in New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subjectto criminal and civil in New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal in New York: Any person who knowingly and with intent to defraud any insurance company or other person files anapplication 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 shall also be subject to a civilpenalty not to exceed five thousand dollars and the stated value of the claim for each such in Ohio.

9 Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits anapplication or files a claim containing a false or deceptive statement is guilty of insurance in Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes anyclaim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a in Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files anapplication 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 such person to criminaland civil in Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in in Tennessee.

10 It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance in Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime andmay be subject to fines and confinement in state in Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance in Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company forthe purpose of defrauding the company.