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ACORD Instruction Guide

This instruction guide was derived from The ACORD organization and is included in the desktop version of Forms Boss Plus. To access this information form the desktop version press F1 while in Forms Boss Plus. To search for a form inside of the PDF reader click Edit Find the type in the form name or number.

Professional Liability Supplement 187 (3/98)

Use this form to apply for professional liability coverage for any of the following classes: Barbers and Beauticians Funeral Directors Optical and Hearing Aid Establishments Printers Veterinarians This form is intended to be used as a supplement to the following forms: ACORD 125 Commercial General Liability Section ACORD 160 Business Owners Application ACORD 165 Small Commercial Account Package App

Commercial Auto Driver Information Schedule 163 (11/2000)

Use this form with either ACORD 127, Business Auto Section, ACORD 128, Garage and Dealers Section, or ACORD 132, Truckers/Motor Carriers Section, to record driver information when there is not enough space in ACORD 127, ACORD 128 or ACORD 132 to accommodate the number of drivers of the applicant's or the insured's vehicles. INSTRUCTIONS It is necessary to collect information on all drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business. Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes. Name Enter driver's full name. If the company requires the address, enter it as well. Sex Enter F for female, M for male. Mar Stat Enter the marital status for each listed driver. Examples: S=Single M=Married D=Divorced SP=Separated W=Widowed Date of Birth Enter driver's birth date. Yrs Exp Enter the number of years of driving experience for each driver. Year Licensed Enter year in which the driver was first licensed. Driver's License Number/Soc. Sec. # Enter complete driver's license number. If a license number is unavailable, enter the driver's social security number. State Lic. Enter the state in which the license was issued.

Date Hire Enter the date of hire for each listed driver (MM/DD/YY). Use Vehicle # Enter the vehicle number that this driver primarily uses. % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.

Restaurant/Tavern Supplement 185 (2/2001)

Use this form in conjunction with ACORD 125, Commercial Insurance Application - Applicant Information Section. This form is intended to be used as a supplement to the following forms, when insurance is desired for restaurants, diners, banquet halls, taverns, night clubs, and other risks that provide food and/or beverage service: ACORD 126, Commercial General Liability Section ACORD 140, Property Section ACORD 160, Business Owners Application ACORD 165, Small Commercial Account Package Application IDENTIFICATION SECTION DATE Month/day/year in which the form is completed. PRODUCER Producer's name, address, and telephone number. CODE Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. SUBCODE If the agency uses a sub-code identification system with this company, enter the appropriate code. AGENCY CUSTOMER ID Customer's identification number assigned by the agency. APPLICANT INFORMATION APPLICANT Full name of the applicant as it appears on ACORD 125. LOCATION OF PROPERTY Provide the street address as it appears on ACORD 125. TYPE OF BUSINESS Identify the type of business conducted. Also check the appropriate boxes to indicate if the business is franchised, not franchised, seasonal or year round. HOURS OF OPERATION Provide the hours of operation. GENERAL INFORMATION This section is designed to inform the underwriter about the past financial condition of the owner or corporation, the type of entertainment provided, if any, the original and subsequent use of the building, and the number of employees Also indicate if the building owner is to be named as an additional insured on the policy. BED & BREAKFAST INN ONLY

Complete this section if the risk is a bed & breakfast inn. KITCHEN FIRE PROTECTION This section is intended to provide sufficient information about the cooking equipment fire protection maintenance, and installation to enable the underwriter to assess the risks involved. Use the Remarks section to explain "no" answers. GENERAL LIABILITY This section is intended to provide information related to the operation of this type of business that is not found in ACORD 126, General Liability. LIQUOR LIABILITY Complete this section if liquor liability coverage is to be provided. Use the Remarks section if more space is needed to provide responses. FINANCIAL INFORMATION Use this section to provide information about the financial condition of the business during the most recent 12 month period. It is not necessary to complete this section if adequate financial statements are attached.

Contractors Supplement 186 (9/2001)

Use this form as a supplement to ACORD 126-S, Commercial General Liability Section, ACORD 160, Business Owners Policy Application, or ACORD 165, Small Commercial Account Package Application, when applying for commercial insurance for the following contractor classes: · Air Conditioning and Heating · Cabinetmakers · Carpentry · Electrical Wiring · Excavation and Grading of Land or Septic Installation · Insulation · Landscaping · Masonry · Painting · Plumbing · Roofing IDENTIFICATION Date Month/day/year on which the form is completed. Producer Producer's name, address, telephone number and fax number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on ACORD 126-S, ACORD 160, or ACORD 165. Type of Contractor Show the contractor class as described in ACORD 126-S, ACORD 160, or ACORD 165. Also provide the number of years

experience in this line of work. Contractor's License Number Show the state or local license number for the applicant, and indicate if the license holder is the owner, an officer, an employee of the business, or other individual or entity. Number of Employees, Percent of Work Show the total number of full-time and part-time employees, the percent of work that is residential, commercial, new construction and remodeling. Gross Receipts, Payroll, Subcontracted Work Show the total dollar amount of gross receipts, payroll, and subcontracted work for the past 12 months. Minimum GL Limits Show the minimum liability limits, per occurrence and aggregate that are required of subcontractors. Indicate if any work is done in or around the following exposures. Answer this question for all applicants regardless of risk class. Explain all "yes" responses. General Information Answer these questions for all applicants regardless of risk class. Explain all "yes" responses. Specific Contractor Information Answer only those questions that apply to the applicant's class of contractor.

Agriculture Application 401 (10/2001)

The underwriting process for any Agriculture account begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Agriculture Application - Applicant Information Section. The Applicant Information Section is the foundation on which the ACORD Agriculture application program is built. This form contains information that is not duplicated on other ACORD application forms. The Applicant Information Section is a required part of every Agriculture submission, and no commercial application is complete without it. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Phone Fax (A/C, No, Ext) Producer's telephone and fax numbers. Producer Producer's name and address. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company and its' NAIC code.. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. Company Policy or Program Name Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed. Show the program code assigned by the company, if applicable. Also show the account number assigned by the agency or by the company, if applicable.

New/Rnwl Indicate if the applicant is a risk that is new to the company or a renewal of an expiring policy with the same company. Effective Date Date on which the terms and conditions of the policy will commence. Expiration Date Date on which the terms and conditions of the policy will terminate unless renewed. Direct Bill/Agency Bill Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. Examples: · Prepaid · Annual · Semi-annual · Bi-monthly · 40-30-30 Status of Submission Indicate whether the company's response to this application is expected to be a quote or an issued policy. If the risk is bound, list the date and time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes. Also show the deposit premium amount. Sections Attached A checklist indicating the other ACORD application sections that are attached to complete the submission. If there are any other additional forms attached, enter the form name on the blank lines. The form numbers associated with the listed section names are: · Agriculture Property Section - ACORD 402 · Agriculture Property Section, Scheduled and Unscheduled Personal Property -ACORD 403 · Agriculture Liability Section - ACORD 404 · Agriculture Application Premises Diagram- ACORD 405 · Commercial General Liability - ACORD 126-S · Auto · For personal auto, use the ACORD 90 application for the state where the vehicles are located. For commercial auto, use Business Auto, ACORD 127, or Truckers, ACORD 132. · Umbrella · Use Personal Umbrella, ACORD 83, or Commercial Umbrella, ACORD 131-S. · Personal Inland Marine · Use ACORD 81. APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) Full name of the applicant as it should appear on the policy. (The first named insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names. (E.g., John and Mary Smith.) Wording such as "et al" or "As their interests may appear" is not acceptable as the name of the insured. These phrases do not designate legal entities. Also show the Federal ID Number (FEIN), or the applicants social security number, if no FEIN.. Mailing and EMail Address (of First Named Insured) The physical address at which the first named insured is to receive all correspondence regarding the insurance. Include the phone number and email address at that address. Form of Business Organization Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, or Other. If other, provide a description such as an Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section, list each named insured along with its form of organization.

Date Business Began The date the applicant began in this business. This is important because it helps the underwriter determine the expertise and business success of the applicant. SIC Enter the Standard Industry Classification code that the applicant falls under. Contact Name and phone number of the person the carrier is to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. TYPE OF FARM/RANCH Indicate the primary nature of the applicant's operation. Refer to your company for specific details, as they apply to the company's individual programs. Describe Farm/Ranch Operations This item is designated to inform the underwriter of what type of operation each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. PREMISES INFORMATION For each separate premises, show the total acreage, number of acres cultivated or in pasture, and indicate whether the business is farmed by the owner of the property, a tenant, a manager, or another entity. Show the gross receipts in dollars. Indicate if the applicant has any other business, whether or not this business has been transferred within the agency, and the date when the premises was last inspected by the producer. LOSS HISTORY Whenever possible, attach a copy of the previous carrier's loss run for each line of business. Loss reports should cover the previous five years of loss history. Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim. Type of Loss Indicate the line of business involved in the loss. Description Give a brief description of the loss. Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date. If the claim is still open, list the reserve amount the previous carrier is holding open for this claim. PRIOR INSURANCE INFORMATION Indicate the prior carrier(s), type of insurance, policy number(s), and amount(s) of coverage. If any coverage was cancelled or non renewed, explain the circumstances surrounding this situation. The questions cannot be asked in Missouri. GENERAL INFORMATION -PROPERTY Answer guestions 1 through 6 if Property insurance is being requested. GENERAL INFORMATION -LIABILITY. Answer questions 1 through 28 iif Liability insurance is being requested. Explain all "yes" responses under remarks. If necessary, use additional sheets of paper. REMARKS Use this section to provide any additional information required for underwriting or rating. If necessary, use additional sheets of paper.

Agriculture Property Section 402 (10/2001)

This guide provides the user with basic instructions for completing the ACORD Agriculture Property Section Application. The Property Section has been designed to handle the basic underwriting and rating needs for Agriculture property exposures. The Property Section accommodates a single location. This form was designed to be used in conjunction with the Agriculture Application - Applicant Information Section (ACORD 401). Please turn to the chapter on the ACORD 401 for information on that form. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 401. Even though this data matches the data on ACORD 401, it is still important to complete it. Many companies separate the applications by sub-line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name and address. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Named Insured/Applicant's Name Show the named insured or applicant exactly as shown on ACORD 401. . Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date Enter exactly as shown on ACORD 401. PREMISES INFORMATION Location # Enter the location number used by the applicant, if applicable. Farm Name Enter the farm name used by the applicant, if applicable. Address Enter the address of the location to be insured. Use route number, distance and direction from nearest crossroads, and section, township and/or range if applicable in your state. Also include the legal description of the farm, as it will appear on the policy. Fire District Name/Code Number Enter the fire district name and corresponding five-character code number for the location. Distance to Fire Station Distance in miles from the nearest fire station, to support the protection class used. COLUMN HEADINGS Description of Property The principal dwelling, household and personal property located in that dwelling and snowmobiles are pre-printed in this column. For other property such as additional dwellings, barns, stables, outbuildings, provide a brief description. Show all buildings or structures to be insured. Be sure to show contents separately, and indicate the occupancy of each building or

structure. Bldg # Show the building number if applicable. Diag # Show the number used on the diagram on ACORD 405. Construction Indicate the building's construction type: Fire Resistive (FR); Modified Fire Resistive (MFR); Masonry Non-Combustible (MNC); Non-Combustible (NC); Joisted Masonry (JM); Frame (F). Type of Heat Type of heating device for the structure. If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. Possible types include: · Electric - Permanent/Portable Natural Gas · Liquid Propane - Permanent/Portable, Oil · Kerosene - Permanent/Portable · Coal - Professionally/Non-Professionally Installed · Wood · Solar · Other - Explain the heating system in Remarks section Year Built Show the year the building was completed. Roof Improve Year Show the year the roof was resurfaced, if applicable.. Square Feet Enter the square footage of the structure. RC/ACV Indicate if replacement cost (RC) or Actual Cash Value (ACV) valuation is to apply. Coins Enter the coinsurance percentage that is to apply. Prot. Class Enter the protection class that applies to the structure. Note that some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply. Dist To Hyd Show the distance in feet to the nearest hydrant. Causes of Loss Show the causes of loss (perils) that are to be covered. Deductible Deductible amount that is to apply. Value Show the current value of the structure or property. Limit of Insurance Show the limit of insurance that will apply. Premium Show the premium for each item. Additional Coverages/Restrictions/Endorsements/Rating Information Use this space to provide necessary information not provided elsewhere. ADDITIONAL INTERESTS Provide information about mortgage holders, loss payees, or other additional property interests, if applicable. The back of the form contains a second PREMISES INFORMATION section that may be used to describe additional premises.

Agriculture Property Section, Scheduled and Unscheduled Personal Property 403 (5/2000)

This guide provides the user with basic instructions for completing the ACORD Agriculture Property Section, Scheduled and Unscheduled Personal Property. This form has been designed to handle the basic underwriting needs for Agriculture personal property exposures. The form was designed to be used in conjunction with Agriculture Application - Applicant Information Section, ACORD 401. Please turn to the chapter on ACORD 401 for information on that form. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 401. Even though this data matches the data on ACORD 401, it is still important to complete it. Many companies separate the applications by subline of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/Day/Year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customers identification number assigned by the agency. Named Insured / Applicant's Name Show the named insured or applicant exactly as shown on ACORD 401. Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date Enter exactly as shown on ACORD 401. GENERAL INFORMATION 1. Is any property kept on a location (s) other than an insured location? If the answer to this question is yes, state where it is kept and indicate whether the storage is during the farming season or off season. 2. What is the maximum value of equipment at any one location? Provide maximum value in dollars, both during the farming season and in the off season. 3. Is any equipment loaned to/from others? If yes, provide the value for borrowed or rented equipment. 4. What is the radius of operations of equipment? If any insured equipment is used or travels off premises, indicate the radius in miles for each piece of equipment. 5. Is equipment well maintained? Describe type of maintenance performed. SCHEDULED FARM PERSONAL PROPERTY Description Provide a complete description of each item shown separately. Indicate premises location. Causes of Loss Show the causes of loss (perils) that are to be covered. Coins Enter the coinsurance percentage that is to apply. Deductible Deductible amount that is to apply. Limit of Insurance Show the individual limits of insurance that will apply. Premium Show the premium for each item. Transit/Hay, Miscellaneous Machinery, Tools, Equipment

These items are preprinted on the form. Space is also provided to show scheduled hay located off premises, if applicable. UNSCHEDULED FARM PERSONAL PROPERTY This schedule is designed to collect information about: Produce Poultry Livestock Machining and Implements Cultivating Harvesting Tools, Equipment and Supplies Irrigation Equipment Any other unscheduled Agriculture personal property Enter the number of units, unit price, total value, applicable causes of loss (perils) to be insured against, applicable coinsurance, deductible(s) and premium. If blanket coverage is desired and any personal property is to be excluded from this method of coverage, list the specific items to be excluded in the section provided.

Agriculture Liability Section 404 (5/2000)

This guide provides the user with basic instructions for completing ACORD Agriculture Liability Section. This form was designed to handle the basic underwriting needs for agriculture liability exposures. If the risk is to be provided with commercial general liability rather than farm liability coverage, use ACORD 125, Commercial Insurance Application, and ACORD 126-S, Commercial General Liability Section. For umbrella or excess liability coverage, use either ACORD 83, Personal Umbrella Application, or ACORD 131-S, Umbrella Section. This form was designed to be used in conjunction with Agriculture Application - Applicant Information Section, ACORD 401. Please turn to the chapter on ACORD 401 for information on that form. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 401; it is still important to complete it. Many companies separate the applications by subline of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customers identification number assigned by the agency. Named Insured/Applicant's Name Show the named insured or applicant exactly as shown on ACORD 401. Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date Enter exactly as shown on ACORD 401. Coverages Provision is made for recording Bodily Injury and Property Damage Liability, Personal and Advertising Injury Liability Medical Payments, Fire Damage Coverage, Damage to Property of Others, and Personal Liability Coverage (AAIS), if applicable. For other combinations of liability coverage, use the blank lines. Show separate limits where applicable. Note that different aggregate limits may apply to separate coverages or exposures. Consult your company manual for applicable rules. If Commercial General Liability is to apply, use Acord 125-S, Commercial Insurance Application, and ACORD 126-S, Commercial General Liability Section. Code Enter the applicable ISO, AAIS, or company code for each type of exposure. Descriptions of coverage have been provided that track with ISO or AAIS rules. If company unique rules apply, use the blank spaces provided. Show Increased Limit Factors, Basis Rates and Premium for applicable exposures. GENERAL INFORMATION 1. Are independent contractors hired to perform any farming operations?

If yes, describe the operations and indicate if certificates of insurance are obtained. 2. Any part of the farm used or leased for organized recreational use? If yes, describe the activities. 3. Does applicant build, repair or design machinery, equipment or systems for anyone at a charge or fee? If yes, describe the operation(s) in detail. 4. Does applicant mix, process, slaughter, butcher or otherwise prepare any "end consumer" this or any other grower's product? If yes, describe in detail. 5. Does applicant handle any product, such as seed, fertilizer, sprays, etc. For resale? If yes, describe the process in detail. 6. Are any contract or service operations performed for others such as, snow removal, tilling, excavating or ditching? If yes, describe the operation and indicate the time period when such operations are performed. 7. Are the farm premises open to the public for activities such as roadside stands, "U-Pick," Recreational, Rent A- Garden, Auction, Sales, Show, Food or Beverage Service, Animal Boarding, or Christmas tree sales uses? If yes, describe in detail. 8. Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other than farming? If yes, provide the name(s) of the individuals or corporation and the use of the premises. 9. Is there any unusual hazard such as (but not admitted to) open dump pits, silage pits, sump holes, lakes or reservoirs? If yes, describe in detail. Also indicate if any safety measures are in place. 10. Is there an airstrip on the premises? If yes, provide the length of the runway, and indicate the type and size of aircraft that use the air strip. 11. Are any "Hold Harmless" or "Indemnifying" agreements in effect? If yes, provide a copy of the agreement. 12. If livestock is kept, are all areas adequately fenced? If the areas are not adequately fenced, describe the measures taken to protect the livestock. 13. Are the described insured premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other than business property? If no, explain. 14. Any non-owned horses on any insured premises? If yes, indicate which premises and describe the operation. Include the number of horses. 15. Does insured board, race, breed, or rent horses? If yes, describe. Include the number of horses. 16. Is any land held for real estate development or speculation? If yes, indicate the area involved and the intended use of the land. 17. Does applicant maintain any vacation or seasonal premises? If yes, indicate which premises and which structures are involved. 18. If dairy farm, is there any processing of milk? If yes, describe the process and indicate how the milk is protected. 19. If dairy farm, is there any retail sales of milk products to public? If yes, show the dollar amount of receipts. 20. Show the number of cows milked. 21. Any premises used for hunting purposes? If yes, indicate whether the hunting is by the owner, or if the premises is rented to others. Show fees and receipts, if any. 22. Does applicant maintain a non-farm office or private school in an insured building? If yes, describe. 23. Is there a swimming pool on premises? If yes, indicate if there is a diving board, and if the pool is adequately fenced. 24. Does applicant serve on any boards for remuneration? If yes, describe.

25. Is the applicant a subsidiary of another or does the applicant have subsidiaries? If yes, describe. 26. Is a formal safety program in existence? If yes, describe. 27. Does applicant have any potentially dangerous animals or exotic pets? If yes, give the age, breed or other information about livestock or pets that may be dangerous to human beings. Also give the history of biting or causing injury. 28. Is there a water craft or snowmobile exposure? If yes, describe.

Mobile Home Application 85 (1/2002)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Mobile Home Application. APPLICANT INFORMATION Previous Address Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address. Location of Property if Diff From Above Enter the physical address of the property to be insured only if it is different from the mailing address listed above. Applicant's/Co-Applicant's Occupation Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed. Applicant's/Co-Applicant's Employer Name and Address Name and address of the organization that employs the applicant(s) named in the identification section. Yrs in Curr. Occ. Number of years in current occupation or business. Yrs w/Curr. Empl. Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section. Yrs w/Prior Empl. Number of years with the prior employer. Mar Stat Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Birth date of each named applicant (MM/DD/YY). (E.g., March 7, 1944 should be 03/07/44.) Social Security # Social security number for each named applicant. Questions relating to agent's knowledge of applicant and when property was inspected Indicate how long the agent has known the applicant, and the date when the property was last inspected. ADDITIONAL INTEREST Provide the following information for each entity having an interest in the mobile home(s) to be insured: the interest

number or rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is held), or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number. COVERAGES/LIMITS OF LIABILITY List the anticipated dollar limit amounts for each applicable coverage. Deductible & Type Enter the deductible amount and the type (Flat, Percentage,) The deductibles may vary from one amount for all perils to different deductibles for various coverages.. Endorsements Enter the name of each applicable endorsement, and the applicable limit of coverage, if any. Premium Enter the estimated total premium, the deposit paid by the applicant, and the balance due later. Payment Plan Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment. RATING UNDERWRITING INFORMATION Year The model year for the mobile home, not necessarily the year the unit was manufactured. Make and Model The name of the manufacturer. ID Number The unique identification number for this mobile home. Length/Width Mobile home's exterior length and width, expressed in feet. Purchase Date/Price Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format. New/Used Check the box to indicate if the mobile home was purchased new by the applicant, or if it was purchased from a previous owner. Cooking Location Check the appropriate box to show the location of the cooking equipment within the mobile home. Tie Down Check the appropriate box to indicate the type of tie down, if any, used to secure the mobile home from wind damage. Terr Code Location of the mobile home based on individual state bureau or company manual pages. Fire Prem Group The applicable premium group based upon the mobile home's location, construction and fire protection code. Some companies require this data; others generate it. EC Prem Group Extended coverage, broad form and special form premium group number determined from the territory. Pers Liab Terr Code Provide the territory code determined by the dwelling's location if the company's rate structure requires separate rating information for personal liability. Protect Class Four character fire protection class found in individual state manuals. Distance to Hydrant Distance (in ft.) from the nearest hydrant that supports the protection class used.

Distance to Fire Station Distance in miles from the nearest fire station that supports the protection class used. Fire District/Code Number Fire district name and corresponding five character code number which can be found in the individual state manual pages. Protection Device Type For alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. Heat Type Type of heating device for the residence. If the residence has no heat, check the box. If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. If fuel storage tanks are located on the premises, describe the type and indicate the location. Possible types include: · Electric - Permanent/Portable · Natural Gas · Liquid Propane - Permanent/Portable · Oil - Permanent/Portable · Kerosene - Permanent/Portable · Solar · Coal - Professionally/Non-Professionally Installed · Wood · Other - Explain the heating system in Remarks section · Central Heating Housekeeping Condition An evaluation of the interior upkeep of the mobile home. Occupancy Indicate by whom the mobile home is currently occupied: owner, tenant, no occupants, or the mobile home is vacant. Use Indicate if the mobile home is the applicant's primary or secondary residence, or if the use is seasonal, or rented to others. Exterior Construction Chech the appropriate box. Foundation Construction Check the box that most closely describes the type of foundation. Utilities Check the appropriate boxes to indicate which utilities are permanently connected to the structure. Wiring Check the appropriate box to indicate copper or aluminum wiring, and show the date the wiring was las inspected. OTHER STRUCTURES Describe any other structure(s) and coverage limits to be included in Coverage B - Other Structures. LOCATION INFORMATION If the mobile home is located in a mobile home park, give Yes or No answers to the questions relating to park management and access to the park. If the mobile home is not located in a mobile home park, give Yes or No answers to the questions relating to visibility from the road and road paving. GENERAL INFORMATION QUESTIONS Use the remarks section to provide additional information for any questions answered with a "Yes" response. 1. Any business conducted on premises? Describe the business as well as where the business is conducted on the premises. 2. Any supplemental heating? Describe any portable heating devices, such as electric, kerosene or LP gas heating units.

3. Any flooding, brush hazard, fire hazard, landslide, etc. Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph. 4. Any other residence owned, occupied or rented? Use the Remarks section to detail the occupancy or use of the other residence. If no liability coverage is requested for this residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property. 5. Has applicant had a foreclosure, repossession or bankruptcy during the past five years? Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing during the specified time period. 6. Are there any animals or exotic pets kept on the premises? Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others. 7. Is property located within two miles of tidal water? Use the Remarks section to describe the coastal hazard, if applicable. 8. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description. 9. Any other insurance with this company? Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. 10. Has insurance been transferred within agency? Indicate why this insurance has been moved from the last company. 11. Any coverage declined, cancelled, or non-renewed? Explain the circumstances surrounding this situation. This question cannot be asked in certain states. 12. During the last five years (ten in RI), has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. LOSS HISTORY This section shows the losses this applicant has had in the past. List losses for the last three years unless the company requires a different period of time. PRIOR COVERAGE Prior Carrier Provide the prior insurance company's name. Prior Policy Number List the complete policy number including prefix and suffix. Risk New to Agency Indicate whether this is the first time this agency has written this line of business for this applicant.

Flood Insurance Application 301 (3/97)a

This form was developed at the request of the National Flood Insurance Program. It may be used to apply for flood insurance. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more information, call the NFIP at 1-800-720-1093.

Flood Insurance Cancellation / Nullification Form 304 (3/97)

This form was developed at the request of the National Flood Insurance Program. It may be used to request cancellation of a flood insurance policy. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more information, call the NFIP at 1-800-720-1093.

Flood Insurance General Change Endorsement 302 (3/97)

This form was developed at the request of the National Flood Insurance Program. It may be used to request changes in existing flood insurance policies. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more information, call the NFIP at 1-800-720-1093.

Flood Insurance Preferred Risk Policy Application 303 (6/98)

This form was developed at the request of the National Flood Insurance Program. It may be used to apply for a Preferred Risk Policy. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more information, call the NFIP at 1-800-720-1093.

Schedule of Insurance 159 (7/2000)

IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producers name, address, phone and fax numbrs. Code Identification code assigned to the agency or the brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, use the apporpriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. NAIC Code The company code assigned by the National Association of Insurance Commissioners. Page If more than one ACORD 159form is required because of the number of properties to be included, indicate the page number applicable and the total number of pages. (e. g., page 1 of 5, page 2 of 4.) Insured/applicant Show the name of the insured or applicant as it appears on the policy. Effective Date Enter the effective date of the policy. Headquarters Address Enter the principle address of the insured. Coins % Check the applicable coinsurance percentage, if applicable. Applicable Cause of Loss Indicate the cause of loss for the subject of insurance. Class Code Enter the ISO or company class codes, if applicable. Location#/Bldg#/Decscription and Location of Property For each building, enter the location number, building number and address shown on the application or change request that was used when the building or the contents was first insured. Provide a description of the property where necessary.

Use more than one line if additional space is needed. Subject Enter the applicable Subject number for each item of insurance, as shown in the instructions at the bottom of the form (e. g., B = building, S = stock.) Limits of Insurance Enter the limits of insurance for each separate item.

Premium Payment Supplement 610 (5/2000)

Use this form as a supplement to any ACORD application, to record pertinent information relating to premium payments involving bank transfers, payroll deductions, credit card deductions, and similar transactions. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant's Name and Mailing Address First Named Insured as it appears on the basic application to which this supplement will be attached. Company, Policy # Name of the applicable insurance company and policy number of the policy involved in the payment transaction. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. Is the Premium Financed? Check the applicable box. Finance Company Name of the finance company, if applicable. Payment Interval Check the applicable box. Payment Due Date(s) Indicate the dates on which the payment transactions should occur. Payment Method Select the applicable payment method and provide the required information to activate that method.

Agriculture Premises Diagram (5/2000)

Use this form as an attachment to ACORD 401, the basic agriculture insurance application to provide a diagram of the premises to be insured. Use a separate form for each premises.

Texas Windstorm Insurance Association Application for Windstorm and

Hail Insurance 64TX (2/2000) Accounts Receivable/Valuable Papers 145 (11/94)

This chapter provides basic instructions for completing the ACORD Accounts Receivable/Valuable Papers section which addresses the basic underwriting and rating needs for both Accounts Receivable and Valuable Paper coverages written under an Inland Marine or Property policy. As much information as possible should be collected regarding receivables and valuable papers to evaluate the particular risk. All questions regarding the particular risk must be completed. Attach a separate sheet if necessary. Accounts Receivable is on the front side of the form and Valuable Papers on the reverse side Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. However, it is still important to complete it. Many companies separate the applications for rating purposes by line of business. Failure to complete this part of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e. g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code: A S Q M O annual semi-annual quarterly monthly other

ACCOUNTS RECEIVABLE Building Construction Construction of the premises location. Common construction classifications are: Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive Fire Resistive Sprinklers Indicate if there are fire sprinklers on the premises. Classification of Business Indicate all classifications of business in which the applicant is involved by placing an "X" in all appropriate boxes. Specify the percentage of the total accounts receivable each classification represents. LOCATION OF RECORDS/PROTECTION Complete this section in regard to the location and protection systems for the Accounts Receivable. Information on the classification of safes, vaults and alarm systems can be found in the Crime Section of the ISO Classification and Rating Manual. Address or Location

Indicate the address where Accounts Receivable are kept. This might also appear in the Applicant Information Section (ACORD 125). If so, indicate "per ACORD 125" and list the location number. Section of Building Specify the section of the building where records of Accounts Receivable are kept; e.g., warehouse vs. office (separate fire rate) and floor have underwriting importance. If other than office, explain. Fire Contents Rate Indicate the 80 percent coinsurance (Basic Group I Personal Property Rate) for the section of the building where Accounts Receivable are usually kept. Safe/Vault/Receptacle Manufacturer If records are kept in a safe, vault or other receptacle, enter the manufacturer's name. Label Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe Manufacturers National Association (SMNA). Class Record the construction classification which represents the extent of fire protection for this safe or vault. Use the classification from the Fire label and not the Burglary label located on the safe or vault. For industry definitions of the classifications, refer to the Commercial Lines Manual. Door Type Indicate if the door is round or square. Combination Locks Identify the presence of combination locks as well and their placement on the safe/vault. Place an "X" in all boxes that apply. Door Thickness Measurement in inches. Wall Thickness Measurement in inches. Construction Specify the construction of the safe, vault or other receptacle (e.g., 4-inch steel door, with 12-inch reinforced stone walls). Duplicate Records Indicate if duplicate Accounts Receivable records are kept by checking the appropriate box. Percent of Records Duplicated Indicate what percent of all Accounts Receivable have duplicate records. Period Records Kept Indicate the number of months all duplicate records will be maintained. Location of Duplicate Records Indicate the address of the location where duplicate records are kept and the precise storage location or section of the building. Alarm Type Indicate the style of alarm(s) where the Accounts Receivable's are stored. Available options are: Hold-Up - Manual or semiautomatic control which can transmit an alarm in the event of a hold-up. Premises - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The Premises Extent must be completed for Premises Alarms. Safe/Vault - System that protects the safe or vault and is connected to an outside central station, gong or siren. The Extent of Protection for Safe/Vault must be completed for all safes/vaults. Alarm Description Indicate any applicable features of the alarm. Local Gong - Bell located outside the premises. Central Station - Private security service which monitors the alarm system and may dispatch security officers in response to an alarm. Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private control station. With Keys - Indicate if security service or police have keys to respond to alarms. Grade Grade or class A, B, C, etc. which indicates the time required to respond to a signal from the alarm system. Refer to manual. Extent of Protection for Safe/Vault

Indicate the extent of the alarm protection for the safe or vault. Partial - Alarm covers around door only. Complete - Alarm covers sides, top walls, floor and ceiling. Extent of Protection for Premises Indicate the extent of the premises alarm as defined in the ISO Classification and Rating Manual. Alarm Installed & Serviced By Name of the company installing and servicing the alarm system. Alarm companies often install, maintain, and service the system in addition to providing Central Station facilities. # Guards Number of guards within the premises or at its door while regularly open for business. # Watchpersons Number of watchpersons on the premises retained during non-office hours. Watchpersons Indicate the type of reporting the watchpersons do: Rpt/Cent. St - Report to a central station on an hourly basis. Clock Hrly - Register hourly with an approved watchpersons' clock (Detex Time Clock, etc.) Don't Signal - Do not report or register in any way. Certificate Number Alarms approved by the Underwriters Laboratories (UL) have a certificate. Record the certificate number. (Note: UL certification can apply to the entire system or to individual parts.) Expiration Date UL certificate expiration date. Accessible Openings & Protection Provide information regarding access to the premises. Indicate how many doors exist and if they are protected. Indicate what type of locks are used, and if there is a gate or bars. Other Protection Describe any other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm, if the building has skylights or if windows are visible from the street). POLICY INFORMATION Use this section to track policy limits and coverages. Reporting/Non-Reporting Indicate if Accounts Receivable insurance is requested on a reporting or non-reporting basis. Reporting coverage usually requires monthly reports of the applicant's total Accounts Receivable and is subject to annual premium adjustment. Your Premises - Limit Insurance limit required for Accounts Receivable located on your premises, including branch locations. Not at Your Premises - Limit Insurance limit required for Accounts Receivable located off your premises. In Transit - Limit Insurance limit required for Accounts Receivable in transit. All Covered Property at all Locations - Limit Sum of all Accounts Receivable. HISTORY OF RECEIVABLES Amount of Receivables outstanding as of the last fiscal day of each month of the prior year immediately preceding the date of this application. Specify the month and year for each entry. Deferred Payment Percentage Percentages of total monthly Accounts Receivable currently represented by deferred payment accounts. Uncollected Accounts Amount of uncollectable accounts for each of the past three years by entering the year and amount. GENERAL INFORMATION Use the Remarks section for additional information for any questions answered "Yes." The following overview lists information that should be added to the remarks section for "Yes" responses. 1. Is "Cycle Billing" accounting system used? Indicate if cycle billing is done and specify if original records are microfilmed. Fully describe the cycle billing procedure; attach a separate sheet if necessary. This is similar to billing for credit cards.

2. Are billed and unbilled records kept separate? Indicate location of each set of records. 3. Has there been flooding at any location? Give date and location of flooding. REMARKS Use this section for any additional information required for underwriting or rating. VALUABLE PAPERS LOCATION Building Construction Construction of the premises location. Common construction classifications are: Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive Fire Resistive Sprinklers - Indicate if fire sprinklers are on the premises. LOCATION OF RECORDS/PROTECTION Complete this section as explained in the Accounts Receivable Section for Location of Records/Protection. (Note: This section applies to Valuable Papers and not Accounts Receivable.) POLICY INFORMATION Your Premises - Limit Insurance limit required for Valuable Papers located on your premises. Not at Your Premises - Limit Insurance limit required for Valuable Papers located off your premises. Blanket/Specified Amount If Blanket Coverage is requested, check the appropriate box and enter the blanket amount. If coverage is to be written on a specified amount basis, an agreed amount per item should be entered in the Papers section along with a description of the specified paper. Occurrence Deductible Deductible amount. Can Papers Be Replaced? Indicate if any papers can be replaced. PAPERS Complete this section only if specific insurance is desired on individual valuable papers. # Assign a number to each item listed. Description of Papers Describe the valuable papers to be insured including manuscripts, documents, rare printings, etc. Older items require appraisals; architects' or engineers' plans should be described; deeds and contracts should be categorized. Valuable papers do not include money and securities. Amount Specified amount for each item listed. See Attached List If a separate schedule of Valuable Papers is provided, place an "X" in the box for See Attached List and submit the schedule with this application. REMARKS Use this section for additional information required for underwriting or rating.

Additional Interest 45 (3/93)

The Additional Interest form is used in multiple situations to expand upon the additional interest sections within line of business applications. This form may be used for both personal and commercial accounts. The form is used to secure information on additional interests and certificate holders.

IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Phone (A / C, No, Ext) Producer's telephone number. Code Identification code assigned to the agency or brokerage firm by the Insurance Company receiving this form. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the line of business form to which this form will be attached. Phone (A / C, No, Ext) Applicants telephone number. Effective Date Month/day/year on which the terms and conditions of the policy will commence. Expiration Date Month/day/year on which the terms and conditions of the policy will terminate unless renewed. Co/Plan Name of the insurance company that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. Also, if applicable, indicate the type of plan or policy program (Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company. Policy Number Number assigned by the insurance company for the policy. Account Number Account number to be used for billing purposes. This is the Billing Number assigned by the billing entity. If agency bill, the agency assigns; if direct bill the company assigns. ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance. Interest Indicate all appropriate options for the individual named. Rank Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee. Name and Address List the additional interests name and address. Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number. Certificate Required If a Certificate of Insurance is required check this box. Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured. Item Description If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting.

Automobile Loss Notice 2 (3/2001)

Use the ACORD Automobile Loss Notice (ACORD 2) for the reporting of both commercial and personal lines automobile losses.

IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Phone (A/C, No, Ext) Producer's telephone number. FAX Producer's fax number. Producer Producer's name and address. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company and its' NAIC code. Do not use group names, use the actual name of the company within the group to which you are sending the loss notice. Miscellaneous Info Use this field to list site and location codes for large accounts. It may also be used to enter the claim number on a phonein report. Policy Number Number assigned by the insurance company for the policy. Policy Type Provide the type of policy issued to the insured. E. g., personal auto, truckers, garage liability. Reference Number Insured's claim number or other reference number to identify this notice. CAT # If a catastrophe number has been assigned by the Property Claim Service or other industry organization, enter it here. This is the number assigned to the event that caused the loss being described. Effective Date Date on which the terms and conditions of the policy commenced. Expiration Date Date on which the terms and conditions of the policy will or have expire(d). Date of Accident and Time Enter the date and approximate time the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g, 01/11/94 - 12:15 A.M.). Previously Reported Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If not, list in the remarks section when other report(s) have been made. INSURED Name & Address Name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if applicable,) of the insured as found on the declarations page of the policy. Residence Phone (A/C, No) For an individual, the home telephone number, including area code, at which the insured may be reached. Business Phone (A/C, No, Ext) Business telephone number, including area code and extension, of the insured.

CONTACT Contact Insured If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address and phone numbers. Name and Address Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is necessary if the "Contact Insured" option is checked. Residence Phone Enter the home phone number including area code of the contact named above. If it is the insured, leave this field blank. Business Phone Enter the business telephone number, including area code and extension of the contact. If it is the insured, leave this field blank. Where to Contact Indicate where this person should be contacted (e.g., home, office, hospital). When Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). LOSS Location of Accident (Include city and state) Indicate street or intersection, mile marker, or a description (e.g., On Route 83 five miles north of the Smallville intersection with Route 59). Authority Contacted Enter the name of the police department or other authority to which the accident was reported, including any precinct or station number, if available. Report # If a case or file number has been assigned, be sure to include that number as well. Usually the report number is the number of the vehicle incident report filed by the police after an automobile accident. Violations/Citations Provide the type of violation/citation and identify the driver who received the citation using driver number. Description of Accident Explain how the accident occurred. POLICY INFORMATION Use this section to list the policy limits and deductibles for the insured as shown on the declarations page. Bodily Injury (Per Person) Used for split limit policies. Enter the Bodily Injury Per Person Limit. Bodily Injury (Per Accident) Used for split limit policies. Enter the Bodily Injury Per Accident Limit. Property Damage Used for split limit policies. Enter the Property Damage Per Accident limit. Single Limit For combined single limit policies, enter the liability limit in this field. Medical Payment Indicate the limit (if any) provided for Medical Payments. OTC Ded. Other Than Collision (OTC) Deductible. If physical damage coverage other than collision is provided, enter the deductible amount. If there is no deductible, enter ACV (Actual Cash Value) or other basis. If no coverage is provided, enter N/A. Other Coverage & Deductibles Describe any additional coverages and deductibles provided on the policy (e.g., No-Fault, Towing, Full Coverage Glass).

Loss Payee Enter the name of any Loss Payee for the auto involved in the loss. If none, enter N/A. Collision Ded. Collision Deductible. If Collision coverage is provided, enter the deductible amount. If no coverage is provided, enter N/A. Umbrella/Excess Indicate if such a policy is in force by checking the appropriate box. Also list the carrier. Enter the umbrella or excess policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the applicable self insured retention or deductible. INSURED VEHICLE Use this section to describe the insured's vehicle and the driver involved in the loss. Information entered should correlate to the insured's declarations page whenever possible. Veh. No. Vehicle Number. Indicate the number assigned to the vehicle as it appears on the policy declarations page. Year Model year of the vehicle. Make Vehicle's manufacturer (e.g., Buick). Model Manufacturer's model name (e.g., Regal). Body Type Vehicle's body type (e.g., two-door sedan). V.I.N. Enter the full Vehicle Identification Number. Plate No. Indicate the license plate number. State State of issuance for the license plate. Owner's Name & Address Enter the name and address of the owner of the vehicle. If it is the insured, enter "insured." Residence Phone Enter the vehicle owner's telephone number with the area code. Business Phone (A/C, No, Ext) Enter the vehicle owner's business phone number with area code and extension. Driver's Name & Address If this is the owner, check the available box. Otherwise, provide the driver's name and address. Residence Phone Enter the driver's home telephone number with area code. Business Phone Enter the driver's business telephone number, including area code and extension. Relation to Insured Indicate the relationship between the driver and the insured (e.g., Insured, wife, child). Date of Birth Indicate the driver's birth date. Driver's License Number Enter the driver's license number. State State of issuance of the driver's license.

Purpose of Use Enter a short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to work). Used With Permission? Indicate if the vehicle was used with the permission of the owner by placing an "X" in the appropriate box. Explain a "no" response in the Remarks section of the form. Describe Damage Describe any damage to the insured's vehicle (e.g., right front fender crushed). Estimate Amount If known, give an estimate for the cost of repairing the vehicle. Where Can Vehicle Be Seen? Indicate where the adjuster can inspect the vehicle. If other than at the insured's address, include the address. When Indicate the time period the vehicle is available for inspection. Other Insurance On Vehicle Provide the company name and policy number on any other applicable insurance. Enter "N/A" if none. PROPERTY DAMAGED Use this section to describe any property other than the insured vehicle (buildings, other vehicles) damaged in relation to this loss. Check the appropriate box to indicate whether or not the damaged property is a vehicle. Describe Property Give a brief description of the type of property damaged, such as home or fence. If a vehicle, list the year, make, model and plate number. Other Veh./Prop. Ins? Indicate if the damaged property (or vehicle) is insured or not. Company or Agency Name Enter the name of the insurance company or agency covering this property (or vehicle). Policy # Enter the policy number for this property (or vehicle). Owner's Name & Address Enter the name and address of the owner of the property (or vehicle). Residence Phone Enter the home phone number, including area code, of the property owner. Business Phone Enter the business telephone number, including the area code and extension, of the property owner. Other Driver's Name & Address If the property damaged is another vehicle, enter the name and address of the driver of the other vehicle. Check the box if it is the same as the owner's name and address. Residence Phone Enter the home telephone number of the driver, including area code. Business Phone Enter the business telephone number of the driver, including area code and extension. Describe Damage Describe the extent of the property damaged (e.g., porch pillar broken, right front fender crushed). Estimate Amount If known, give an estimate of the cost of repair. Where Can Damage Be Seen? Indicate where the damaged property is located, including address, so that an adjuster can inspect it. INJURED

Use this section to collect information on all injured parties. Name & Address Enter the name(s) and address(es) of any people injured in the accident. Phone Enter the home telephone number, including area code of any injured party. PED Indicate if the injured party was a pedestrian by an "X" in this box. Ins. Veh. Indicate if the injured party was in the insured's vehicle by an "X" in this box. Other Veh. Indicate if the injured party was in a vehicle other than the insured's by an "X" in this box. Age Enter the age of the injured party. Extent of Injury Briefly describe the injury to the injured party (e.g., broken left leg). WITNESSES OR PASSENGERS Use this section to describe any additional parties involved in or witnessing the accident. Name & Address Enter the name(s) and address(es) of any witnesses or uninjured passengers. Phone Enter the home telephone number, including area code, of any witness or passenger. Ins. Veh. Indicate if the witness or passenger was in the insured's vehicle by an "X' in this box. Other Veh. Indicate if the witness or passenger was in a vehicle other than the insured's by an "X" in this box. Other Describe any other witnesses. If they were not in the insured's vehicle or other involved vehicle, include the location from which they witnessed the incident. Remarks List any other additional information that will assist in properly reporting and settling this claim. Include the adjuster's name if known. Reported By Indicate the name of the individual who reported the loss. Reported To Indicate the name of the individual within the agency or company to whom this loss was reported. Signatures of Producer and Insured This form should be signed by the producer and the insured. Note: Important state information is on the second side of this form.

Boiler and Machinery Section 155 (11/2000)

This chapter provides basic instructions for completing the ACORD Boiler & Machinery Section (ACORD 155). This form has been designed to address basic underwriting and rating needs for the issuance of Boiler and Machinery policies Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Most information for the Identification Section should match the data found within the Applicant Information Section of

ACORD 125. however it is still important to complete the section. Many companies, for rating purposes, separate the applications by line of business. Not completing this portion of the application impedes tracking the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). SMALL BUSINESS POLICY (Limit Rated) Use section for submissions in conjunction with a business owner's policy (BOP) or to companies issuing Boiler and Machinery policies based on limited rating criteria. Coverage Mark an "X" in the appropriate box for the Coverage desired. Basic Coverage Form Boilers and Vessels are automatically included. Indicate if the basic form includes air conditioners/compressor units or excludes air conditioners/compressor units. Broad Coverage Form Comprehensive coverage that includes boilers, pressure vessels, mechanical and electrical equipment, but excludes production machinery. Other Many companies have independently filed Boiler and Machinery products. Refer to the companies for information needed to rate the product. Spoilage (Consequential Damage) Mark an "X" in the appropriate box for the desired limit. Spoilage is the loss of perishable goods due to lack of power, light, heat, steam or refrigeration. Deductible Mark an "X" in the appropriate box for the desired deductible. General Information Mark an "X" in the appropriate box. Indicate whether Heating (hot water or steam only) or Process Boilers are located on any locations to be covered. If the answer varies by location, use the Additional Information area to note the information. Additional Information List any additional information that would be useful in the underwriting of this account (e.g., age of boiler, building construction). STANDARD POLICY Covered Equipment Mark an "X" in the appropriate box(es) by equipment type box for coverage(s) desired. PD Property Damage BII Business Interruption Insurance Comprehensive Coverage includes Boilers, Pressure Vessels and Mechanical and Electrical Equipment. It may include or exclude coverage for production machines (equipment used specifically for manufacturing or processing of products). If comprehensive coverage is chosen, do not choose any of the "All" categories or complete any "Other" item. All Boilers - Pressure Vessels Indicate which coverage is desired for this type of equipment. All Air Conditioning & Refrigeration Equipment Indicate which coverage is desired for this type of equipment.

All Electrical Equipment Indicate which coverage is desired for this type of equipment. All Mechanical Equipment Indicate which coverage is desired for this type of equipment. Other Object Groups This area may be used to select particular types of Objects that fall within the "All" categories (e.g., Transformers would be one group within the All Electrical Equipment category). Consult with your insurer for more information about object group descriptions. Coverages Refer to the ISO Commercial Lines Manual for standard values, limits, deductibles and other items. Property Damage Limit of Insurance Insurance limit for property damage coverage. This amount should be $100,000 or greater. Property Damage Deductible Property Damage deductible (minimum $250). Extra Expense Limit of Loss Indicate the limit of loss desired for Extra Expense coverage. Extra Expense Period of Restoration Period of restoration percentage for Extra Expense coverage (e.g., an entry of 100 percent would allow the applicant to collect the entire Limit of Loss during the first 30 days after the loss; 40-80-100 would provide up to 40 percent of the limit during the first month, up to 80 percent of the limit the second month, and the remainder the third month. Any limit not used within the 100 percent time frame is collectible for as long as the extra expense continues). Extra Expense Deductible Desired Extra Expense deductible. Business Interruption Choose between Actual Loss Sustained or Valued Form per location. Actual Loss Sustained Complete this section for Actual Loss Sustained. Limit of Loss Percentage of Annual Value to be used for the limit (applies at all locations). Annual Value Annual value for each location. Deductible Desired deductible. Ordinary Payroll Number of days for which ordinary payroll is to be included within the actual loss sustained. Valued Form Complete this section for Valued Form. Daily Limit Desired daily limit. Number of Days Mark "X" in the appropriate box indicating the desired number of days for which the coverage is to apply. Deductible Desired Valued Form deductible. Consequential Damage An indirect loss resulting from loss of use of the property over a period of time. Limit of Loss Desired limit of loss. Coins % (Coinsurance Percentage) Enter the percentage of the total value of the product that corresponds with the selected limit. Deductible Desired deductible. Specified Property

Describe the product being insured. In Storage/In Process Mark an "X" in the appropriate box. In Storage means coverage applies to specified property only while in storage. In Process means coverage applies to specified property while being processed or while in storage. ADDITIONAL INFORMATION Provide any additional information required for underwriting or rating. PREMISES INFORMATION Use section to collect underwriting, rating and contact information on the applicant. Complete one section per each premises location of the risk. Premises Number List the premises location number as stated in the Applicant Information Section (ACORD 125). Machinery and Equipment Values If available, indicate the total (100%) machinery and equipment values for the specified location. If these values are not available, list the Contents value and indicate that the number shown represents a value for Contents at 100 percent. Building Values List the building value (100%) for each location. Inspection Contact Name of an individual for each location who can be contacted for physical inspection of the premises. Phone Number Telephone number for the listed individual. ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS Use section to collect information on any additional interest or receiver of Certificates of Insurance. Prem # Premises location number as stated in the Applicant Information Section (ACORD 125). Name and Address List the Additional Interest's name and mailing address. Certificate Required If a Certificate of Insurance is required, check this box. Interest List the type of interest of the additional interest. Examples: Mortgagee Loss Payee Additional Insured REMARKS Provide any additional information required for underwriting or rating.

Business Auto Section 127 (8/2001)

The Business Auto Section of the ACORD Commercial Insurance Application series contains basic policy information as well as essential underwriting information for commercial auto accounts. Through the effective use of the Business Auto Section, specific needs of an individual account can be addressed. Space is provided to enter driver information for up to ten drivers. For additional drivers, ACORD 163, Driver Information Schedule, can be attached. Space is also provided to enter descriptions of up to eight vehicles. If the fleet should exceed this number, the ACORD Vehicle Schedule (ACORD 129), which contains space for 7 additional vehicles, can be attached. Insurance coverages,"no fault" and uninsured/underinsured motorists coverages in particular, vary widely from state to state. In addition, there are numerous state-specific requirements that apply to Business Auto applications. ACORD 127 cannot address these various unique specifications. Therefore, state-specific forms, ACORD 137, have been developed to respond to these requirements. Use the ACORD 137 for your state to provide coverages/ limits information, as well as the required disclosure and other data unique to the state. See the State Forms section of this Guide for more information. This form was also designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Please turn to the chapter on the ACORD 125 for information on that form.

Many states require supplements to all auto applications, to provide specific coverage explanation or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in all states. Refer to the State Forms section of this Guide. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Phone (A/C, No, Ext)/FAX No Producer's telephone and fax numbers. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Month/day/year on which the terms and conditions of the policy will commence. Expiration Date Month/day/year on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Plan used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . .other COVERAGES/LIMITS Covered Auto Symbols The Business Auto Policy uses numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an "X" in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 1 through 6 provide fleet automatic coverage. Symbol 1 includes Hired and Non-Owned auto coverage. If symbol 1 is not used and Hired auto (symbol 8) or Non-Owned auto (symbol 9) coverage is desired, those symbols must be checked. The symbols indicate coverage for each applicable automobile. The symbols "trigger" coverage. Please refer to the company's policy declarations page for exact policy definitions of the symbols.

Symbol 1 - Any Auto Symbol 1 can only be used for liability insurance. This includes coverage for owned, non-owned, and hired autos. Provides automatic coverage for autos the insured newly acquires. Not to be used for No-Fault, Medical Payments, Uninsured or Underinsured Motorists, or Physical Damage coverages. Symbol 2 - All Owned Autos Applies only to autos owned by the insured, and for liability coverage on any non-owned trailers while attached to power units the insured owns. This provides automatic coverage for autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, or Physical Damage coverages, except Towing and Labor. Symbol 3 - Owned Private Passenger Autos Provides automatic coverage for private passenger autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, Physical Damage, or Towing. Symbol 4 - Owned Autos Other Than Private Passenger Provides automatic coverage for autos other than private passenger the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, and Physical Damage except Towing. Symbol 5 - All Owned Autos Which Require No-Fault Coverage Provides automatic coverage for autos the insured newly acquires where no-fault is required by law. Used only for P.I.P. and Additional P.I.P. Symbol 6 - Owned Autos Subject To Compulsory U.M. Law Provides automatic coverage for autos the insured newly acquires where rejection of U.M. is not permitted by law. Symbol 7 - Autos Specified On Schedule Applies only to those autos described on the schedule for which a premium charge is shown, and for liability coverage on any non-owned trailers while attached to power units the insured owns. Provides no automatic coverage for autos the insured newly acquires. The company must be notified of newly acquired autos within 30 days. Used for all coverages. Symbol 8 - Hired Autos Applies only to those autos leased, hired, rented or borrowed by the insured. This does not include any auto leased, hired, rented or borrowed from any of the insured's employees or members of their households. Can be used for all coverages except no-fault, towing, and labor. For medical payments, this symbol applies only to funeral directors. Symbol 9 - Non-Owned Autos Applies only to those autos not owned, leased, or hired by the insured which are used in connection with the insured's business. Used only for liability coverage. Coverages / Limits - Use ACORD 137 for your state. DRIVER INFORMATION This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business. Driver # Indicate the driver number assigned by the agency/agency-vendor system used for tracking purposes. Name Enter driver's full name. If the company requires the address, enter it as well. Sex Enter F for female, M for male. Marital Stat Enter the marital status for each driver. Examples: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Enter the driver's birth date. Yrs Exp

Enter the number of years of driving experience for each driver. Year Licensed Enter the year in which the driver was first licensed. Driver's License Number/Soc. Sec. # Enter the complete driver's license number. If a license number is unavailable, enter the driver's social security number. State Lic. Enter the state in which the license was issued. Date Hire Enter the date of hire for each driver. Broadened No Fault Certain states "no fault" liability laws permit broadened no fault coverage to be written for specific drivers. If such specific coverage is to apply, indicate "yes" here for each driver that is to be covered. DOC Enter Y in this column for any driver specifically covered by Drive Other Car coverage. Use Vehicle # Enter the vehicle number that this driver primarily uses. % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. 1. With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant? Indicate if any of the vehicles described in the application are not owned by or registered to the applicant. 2. Do over 50% of the employees use their autos in the business? Indicate if more than 50% of applicant's employees use their vehicles in the applicant's business. 3. Is there a vehicle maintenance program in operation? Explain the type of program and if there are maintenance records kept on file. 4. Are any vehicles leased to others? Indicate if autos are leased on a short term or long term basis. Are certificates of insurance required from lessees? List who the vehicles are leased to. 5. Are any vehicles customized, altered or have special equipment? Provide the details on such alterations/customizations. List customized item and estimated value of customization. 6. Are ICC, PUC or other filings required? If Interstate Commerce Commission or Public Utilities Commission filings are required, describe the insured operations and trip frequency. 7. Do operations involve transporting hazardous material? List the materials hauled, safety measures taken and if the applicant is subject to the Federal Motor Carrier Act Requirements. 8. Any Hold Harmless Agreements? If any hold harmless agreements are in force, describe any in which the applicant indemnifies others. Attach a copy of the agreement. 9. Any vehicles used by family members? Provide details regarding which vehicles are used and how often. Make sure the driver is included in the Driver Information section. 10. Does the applicant obtain MVR verifications? Indicate if applicant reviews MVRs on all assigned drivers. How often? Upon hiring only? If No, provide explanation of why MVRs are not reviewed. 11. Does the applicant have a specific driver recruiting method? Describe the recruiting method. Are written and/or road tests conducted?

12. Are any drivers not covered by Workers Compensation? Provide the names of all drivers not covered. 13. Any vehicles owned but not scheduled on this application? List vehicles not to be covered and explain why. Indicate where coverage is placed for these vehicles. 14. Any drivers with moving traffic violations? Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company's and state's requirements. 15. Has agent inspected vehicles? Describe any damage to vehicles, including any missing safety devices. Maximum Dollar Value Subject to Loss List the highest value that the insurer would be subject to if a major automobile loss occurred on the insured premises. Description of Garage/Storage Locations Provide a brief description of all garage or storage locations for the vehicles (e.g., Fenced in secured lot or Closed secured garage). ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an ACORD 45. Interest Indicate all appropriate options for the individual named. Rank Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee. Name and Address List the additional interest's name and address. Reference # Indicate the additional interest's reference number for this applicant such as the loan or mortgage number. Certificate Required If a Certificate of Insurance is required, check this box. Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured. Item Description If needed, further clarify the item of interest in this field. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting. Cert Indicate by "yes" or "no" whether a Certificate of Insurance needs to be issued to the additional interest. VEHICLE DESCRIPTION This section is used to collect pertinent information on the vehicles that are to be insured, what they are, how they are used and what coverage applies to them. If there are more than eight vehicles associated with this risk, place additional vehicles on the ACORD 129 Vehicle Schedule. Veh # Number assigned by the agent to this vehicle for purposes of tracking in the application process. Year Vehicle's model year. Make Vehicle's manufacturer (e.g., Buick). Model Manufacturer's model name (e.g., Regal).

Body Type Vehicle's body type (e.g., 4 door sedan). V.I.N. Full vehicle identification number assigned by the manufacturer. City, State, Zip where garaged List the location where this vehicle is normally garaged. Lic State Enter the state where the vehicle is licensed. Terr Enter the rating territory in which the vehicle is principally garaged. GVW/GCW These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly. GVW Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer. GCW Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which the truck-tractor is designed as specified by the manufacturer. Class This is the primary industry classification code found in rating manuals for commercial vehicles as determined by: · If this is a fleet or non-fleet policy · Commercial autos by size, business use, radius of operation and whether truck or trailer type · Public autos by type of vehicle, radius or seating capacity S.I.C. This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. Factor This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you are not rating this application. Seating Capacity Used for public vehicles and livery vehicles. Enter the number of passenger seats available. Sym/Age Enter the age of the vehicle in years, as follows: · 1-Current model year · 2-First preceding model year · 3-Second preceding model year · 4-Third preceding model year · 5-Fourth preceding model year · 6-All other autos Cost New If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and equipment. Radius Enter the appropriate radius code as follows: L - Local Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging. I -Intermediate Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging. LD - Long Distance Regularly and frequently operated beyond a radius of 200 miles. Farthest Term

For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of this vehicle, that this vehicle travels to. Drive to Work/School If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are: · Drive to Work or School under 15 miles one way · Drive to Work or School 15 miles or over one way Use Check the appropriate box for the primary use of this vehicle. Options are: · Pleasure - Private passenger vehicles or pickups/vans not used for business purposes · Farm - Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch · Retail - Pick up or delivery of property to individual households · Service - Transportation of personnel, tools, equipment or supplies to or from a job site · Commercial - The transportation of property in vehicles other than those defined as retail or service Check Coverages Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the symbols indicated in the coverage section of ACORD 137. Abbreviations are: Liab . . . . . . . . . . . . . . . . . . . . .Liability No-Fault . . . . . . . . . . . . . . . . "No-Fault" coverage, if applicableP Add'l No-Fault . . . . . . . . . . . Additional "No-Fault" Protection, if applicable Med Pay . . . . . . . . . . . . . . . . Medical Payments Unins. Mot . . . . . . . . . . . . . . . Uninsured Motorist Underins Mot . . . . . . . . . . . . Underinsured Motorist Towing & Labor . . . . . . . . . .Towing and Labor Spec C of L . . . . . . . . . . . . . . Specified Cause of Loss F. . . . . . . . . . . . . . . . . . . . . . . . .Specified Cause of Loss by Fire F & T. . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss by Fire and Theft F, T, & W . . . . . . . . . . . . . . . . .Specified Causes of Loss by Fire, Theft and Windstorm LSP . . . . . . . . . . . . . . . . . . . . . . Limited Specified Perils Comp. . . . . . . . . . . . . . . . . . . . .Comprehensive Coverage Coll. . . . . . . . . . . . . . . . . . . . . . .Collision Coverage Deductibles Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt - Stated Amount basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the collision deductible in the space provided. Net Veh Dr/Cr Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under Remarks a description of each debit or credit used in the calculation of the net rating factor. Tot Prem Enter the total premium for the vehicle. REMARKS Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments such as hold harmless agreements, or pictures of vehicles are being sent.

Business Owner's Policy 160 (8/2000)

This application is designed to be used with most business owners and small business policies. The form collects information for coverage for property, liability and additional coverages, such as accounts receivables, boiler and machinery, crime, glass, signs and valuable papers. Space is provided for company-specific additional coverages as well. The form can accommodate specialty programs, such as apartment, condominiums or restaurants. Individual carriers should be contacted for unique underwriting and any other information required by specific companies. IDENTIFICATION SECTION Date Month/day/year on which the form is completed.

Producer Producer's name, address, telephone, FAX and E-Mail numbers. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customers identification number assigned by the agency. Company Name of the applicable insurance company and its NAIC number. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. Company Policy or Program Name Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to indicate an ISO or other rating organization policy type, or to name the subsidiary company where the line of business will be placed. Program Code The code assigned by the company for the program. New/Renwl Indicate if the applicant is new to the company or a renewal of an expiring policy with the same company. Effective Date Enter the Effective date on which the terms and conditions of the policy will commence. Expiration Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Quote/Bound/Issue Policy Indicate whether the company's response to this application is expected to be a quote or an issued policy. If the risk is bound, so indicate and include the date coverage began and attach a copy of the binder. If more than one option applies, check off multiple boxes. Policy Type Include identifying information as requested by company policy. Deposit Enter the dollar amount of the deposit, if any. APPLICANT INFORMATION Name (First Named Insured) Enter the full name of the applicant as it should appear on the policy. (The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as "et al." or "As their interests may appear" is not acceptable as the name of the insured. These phrases are not legal entities. Mailing Address Address at which the First Named Insured is to receive all correspondence regarding their insurance. Address should include: Street number, if any Pre-direction, if any (example: 150 N Central Ave) Street name, if any Street type (examples: st, rd, ave) Post-direction, if any (example: 150 Central Ave N) City County State Zip Code If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal address if required by mortgagee.

Individual, etc. Identify the applicant as an Individual, Partnership, Limited Corporation, Corporation, Joint Venture or Other. If other, provide a description such as Professional Association. If there is more than one Named Insured, provide the form of business organization for each. In the Remarks section list each Named Insured along with its form of organization (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.). GL Code Enter the General Liability Code, if applicable. SIC Enter the Standard Industry Classification code that the applicant falls under. Federal ID # Enter the Federal Employer ID number assigned by the IRS, or, if an individual, their social security number. Contact Name and phone number of the person the carrier is to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. NATURE OF BUSINESS Indicate the primary nature of the applicant's operation. Options available are: Office Apartments Service Condominiums Retail Contractors Wholesale Restaurant Contractor Other (describe) Enter the number of years the applicant has been in business, ISO or Company Class Code, Rate # and Rate Group, if applicable. Refer to your company for specific details with respect to definitions of these elements, as they apply to the company's individual program. DESCRIPTION OF OPERATIONS/OCCUPANCY This section is designed to tell the underwriter what business each applicant performs and the way it is conducted by premises, the number of employees at this premises, and the hours of operation. Operations which may not be apparent in a general description of operations may be segmented by premises. Annual Sales/ Receipts List the projected sales over the last 12 months. Total Payroll List the projected sales over the last 12 months. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual; this does not provide adequate detail. PREMISES INFORMATION Address, Street, City, state, County, Zip Enter the physical street address (not P.O. Box) where the applicant is located. Include premises numbers and building numbers, if applicable. Indicate if the primary location is at this address. Interest Indicate the interest the applicant has at this location. Year Built Enter the year the building was originally constructed. Area Occup. Enter the percentage of the building the applicant occupies. Sq. Ft. Enter the square footage of the building. Surrounding Exposures and Other Occupancies

Describe the buildings, structures, activities conducted, or use of property adjacent to the insured premises and provide the distance from the insured premises. Also include any other occupancies not operated by the insured within the building where the insured is located. Any Area Leased? Indicate if any area of the premises is leased to others by the applicant. Prot. Cl. Enter the fire rating protection class for this location. Rate Terr. Enter the ISO or company rating territory for this location. Fire District / Code No. Enter the name of the fire district within which the property is located, and the corresponding five character code number, and indicate whether or not the property is inside city limits. PROPERTY For each building, and separately for personal property within each building, list the following (use a separate form for each building): Limit The limit of insurance that will apply. % Coins Show the coinsurance percentage, if applicable. If coinsurance does not apply, enter "None." Valuation Replacement Cost (RC), Full Value Replacement Cost (FVRC), or Actual Cash Value (ACV). If other, add name next to available box. INFL% The Inflation Guard percentage that is to apply. Deductible The deductible amount that is to apply. If more than one deductible applies, show all deductibles in the Remarks section. Construction Type Indicate the building's construction type: Fire Resistive (FR); Modified Fire Resistive (MFR); Masonry Non-Combustible (MNC); Non-Combustible (NC); Joisted Masonry (JM); Frame (F). Total Square Foot Area For building coverage, indicate the total square foot area of the building; for personal property, indicate the area in square feet that the applicant occupies. # Apt Units The number of rental units if this is an apartment building or a condominium. # Stories Indicate the height of the building in stories, not including basement. % Sprink The percentage of the building that is protected by a sprinkler system. Basement Indicate if there is a basement and if it has been finished. Building Improvements If wiring, roofing, plumbing or heating have been partially or completely replaced, provide the year updated. Roof Type Enter the material used to construct the roof. Examples: Composition (fiberglass, asphalt, etc.) Metal Poured Slate Tile Wood Shake/Shingle Other - If used, explain in Remarks Bldg. Code Grade Enter the ISO Building Code Grade, if applicable. Tax Code

Enter the city, county or state tax code if required. Wind Class Check the applicable wind class. LIABILITY Limits List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. Deductible Indicate dollar amount or percentage, and coverages to which the deductible is to apply. Classification, Class Code, Premium Basis/Basis Code Use this section only if the Liability portion of the policy is independently rated. Enter the necessary information as instructed by the company. PRIOR POLICY(IES) / LOSS HISTORY Previous Carrier Name of the insurance company that wrote the previous policy. Policy Number Identification number assigned by the insurance company to identify the policy. Exp. Date Expiration date of the previous policy. # Losses Last 3 Yrs. Give the total number of losses. Total Losses Show the total amount, in dollars, of all losses in the last 3 years. Description of Losses Describe any losses, give loss dates and amounts paid. ADDITIONAL COVERAGES Enter the necessary total limits of insurance and applicable deductibles for each additional coverage to be provided for. Options are: Extra expense * Loss of income * Valuable papers Accounts receivable Sign Employee dishonesty Burglary and robbery, stock Burglary and robbery, money Boiler and machinery, basic Boiler and machinery, broad Boiler and machinery spoilage Glass ** Money and Securities - Inside Money and Securities - Outside Spoilage Computers Ordinance or Law ERISA (Employee Dishonesty) Flood Earthquake * If extra expense or loss of income coverages are provided on a 12 month basis rather than with dollar limits, show "12 months" in the Amount column. ** For glass coverage by ground floor and/or above ground floor panes, include the following: # Panes The number of like size panes Area The total area per pane Length The horizontal measurement per pane in linear feet Interior, Tenants Exterior

Check if glass is inside the building or outside a tenant area. Type The type of pane, such as window, jalousie, etc. Value The cost per pane Deductible The deductible for glass coverage GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. 1. Do/have past, present or discontinued operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material? If so, indicate how they are or were controlled, stored or disposed of. Indicate if the applicant owns or operates any landfills or fuel tanks. 2. Are athletic teams sponsored? Indicate if the teams are composed of employees or others such as Little League. 3. Are Certificates of Insurance required from sub contractors? Indicate who checks them, and if coverages are equal or greater than the applicants. 4. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. 5. Any coverage declined, cancelled, non-renewed? If any policy had this action taken, provide the reasons and circumstances. This question cannot be asked in Missouri. 6. Do you lease to or from other employers? If yes, describe the extent of leasing. 7. Is any workers compensation carried? If yes, give company and policy number. 8. Do you own or operate any other business? If yes, provide description of operations. 9. Is there a swimming pool on the premises? If yes, describe the fencing and access. Describe any diving board or water slide. Note if there is a lifeguard on duty when the pool is open. 10. Any other insurance with this company? If yes, provide the policy numbers under Remarks. 11. Are you involved in manufacturing mixing, relabeling or repackaging of products? If yes, describe the process. 12. Do you rent or loan equipment to others? Describe the types of equipment. 13. For retail stores, does installation, service or repair work account for more than 15% of receipts? If yes, give percentage and describe the operation. Describe any location/business interest owned or operated by insured but not listed List any location or risk that is not to be covered within this package policy. SPECIALTY PROGRAMS APARTMENT AND CONDOMINIUMS Is there a playground on premises? Describe the equipment at the playground (e.g., slides, swings, etc.). Is aluminum wiring used? Indicate the date when wiring was done, and indicate if there is also copper wiring.

Number of Units Per Building or Fire Division Enter the number of residences that are in the fire division, including the insured's. Also indicate the percent of the building that is owner-occupied. Indicate where coverage applies to: bare walls, finished walls. If the building is a condominium, indicate if the building coverage is to include bare or finished walls; this information can be found in the condominium association agreement. Smoke Detectors If the building and/or apartment units are equipped with smoke detectors, check the appropriate box. Attach copy of condo association bylaws if Directors and Officers coverage is requested. Also indicate if the developer or contractor is a board member, and if a property manager is employed. RESTAURANTS Attach ACORD 185 for each restaurant location. CONTRACTORS Attach ACORD 186. PROFESSIONAL LIABILITY Attach ACORD 187 for barber and beauty shops, funeral homes, optical and hearing aid establishments, printers or veterinarians. CRIME Complete this section in regards to the location and protection systems for this risk. Information on the classification of safes, vaults and alarm systems can be found in the Crime Section of the ISO Commercial Lines Manual. Alarm Type Indicate the style of alarm(s) protecting this premises, safe or vault. Available options are: Hold-Up The presence of a manual or semiautomatic control which can transmit an alarm in the event of a hold-up Premises - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The Premises Extent needs to be completed for Premises Alarms Safe/Vault - An alarm system that protects the safe or vault and is connected to outside central station, gong or siren. The Extent of Protection for Safe/Vault needs to be completed for all safes/vaults Alarm Description Indicate any applicable features of the alarm. Local Gong - A bell located outside the premises Central Station - A private security service which monitors the alarm system and may dispatch security officers in response to an alarm Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private control station Grade Enter the GRADE or class A, B, C, etc. This indicates the time required to respond to a signal from the alarm system. Please refer to manual. Extent of Protection for Safe/Vault Indicate the extent of the alarm protection for the safe or vault. Partial - Alarm covers around door only Complete - Alarm covers sides, top walls, floor, and ceiling Extent of Protection for Premises Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual. Certificate #/Expiration Date Alarms which are approved by the Underwriters Laboratories (UL), or other nationally recognized testing laboratories, are evidenced by a certificate. Record the certificate number and its expiration date. Safe/Vault/Receptacle Manufacturers Name List the manufacturer's name of the applicant's safe, vault or other secured receptacle. Label Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe Manufacturers National Association (SMNA).

Class Record the construction classification which represents the extent of burglary protection for this safe or vault. Be sure to use the classification from the Burglary label and not the Fire label located on the safe or vault. For industry definitions of the classifications refer to the Commercial Lines Manual. Maximum Cash on Premises Indicate the maximum amount of cash kept on the premises during normal business hours. Maximum Cash With Messenger Indicate the maximum amount of cash messengers are allowed to carry for the applicant. Money on Premises Overnight Indicate the maximum amount of cash left on the premises overnight. Frequency of Deposits Indicate the frequency with which deposits are made to the bank. Examples: daily, twice a week. Dbl. Cyl. Door Locks Indicate if all doors leading into and out of the applicant's premises have double cylinder door locks. Other Protection List any other protection device that the applicant uses. ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance. For additional names, attach an ACORD 45. Interest Indicate all appropriate options for the individual named. Rank Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee. Name and Address List the additional interests name and address. Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number. Certificate Required If a Certificate of Insurance is required check this box. Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured. Item Description If needed, further clarify the item of interest in this field. For a scheduled item list the description, such as 3 carat diamond in six point setting. REMARKS Use this section to provide any additional information required for underwriting or rating. If necessary, use additional sheets of paper.

Business Owner's Supplemental App 161 (11/98)

This form is designed to collect information about two additional premises to be insured under a businessowners or small business policy. Use ACORD 160, Business Owners Application, for the first premises and ACORD 161 for any other premises. All of the premises information sections on this form are identical to sections in ACORD 160. Please refer to the chapter on ACORD 160 for specific element descriptions.

CA Offer of Earthquake Coverage 66CA (2/98)

This form complies with California law, which requires that the named insured for each policy of residential property insurance be offered earthquake coverage as provided by the law. Use ACORD 66 CA with ACORD 80 and ACORD 84.

CA Residential Property Insurance Disclosure 67CA (11/94)

This form complies with California law, which requires that the named insured for each policy of residential property insurance be provided a copy of the California Residential Property Insurance disclosure statement contained in the law. Use ACORD 67 CA with ACORD 80 and ACORD 84.

Cancellation Request/Policy Release 35 (1/97)

This guide provides basic instructions for completing the ACORD Cancellation Request/Policy Release form. It explains information the company needs to process the transaction. This form is used as tangible evidence of the insured's instruction to cancel a contract. It can be used for either Personal or Commercial Lines, or as an enclosure to the returned original contract, when available. Method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. Caution should be exercised to ensure proper signature specifications are followed, as required by the company. Insured entities must have an authorized signature and title where applicable. Individual companies may have specific requirements for additional information particularly in situations of "Policy Rewritten" or "Pro Rata" cancellations. Verify that cancellation notice rights have not been extended to additional parties. Premium financed policies should be discreetly handled to ensure proper transmittal of premium and information. INFORMATION SECTION Date Month/day/year on which the form was completed. Producer Name and address of the producer of record whose policy is being cancelled or released. Phone (A/C, No, Ext) Producer's telephone number. Code Identifying code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name and Address Issuing company's name, NAIC code, and address shown on the policy being cancelled or released. Do not use group or trade name. Policy Type Specific type of insurance (e.g., Automobile Policy, Workers Compensation, Homeowners, etc.). Insured Name and Address Name, mailing address and ZIP code of the insured as it appears on the policy. If the policy is issued to multiple named insureds, and the space is not adequate to list them all, enter only the first named insured followed by "et al." CANCELED POLICY INFORMATION Policy Number Policy Number exactly as it appears on the policy, including both prefix and suffix symbols. Effective Date and Hour of Cancellation List the effective date of the policy cancellation in month/day/year format. Enter the time including, AM or PM, that the

policy cancellation takes effect. Policy Term List the full term effective and expiration dates as listed on the policy. CANCELLATION REQUEST (Policy Attached) If this form is being used to notify the carrier of policy cancellation and the insured's original copy of the policy is attached, check this box and return both this form and original policy to the company. POLICY RELEASE (Complete Statement Section below) Policy Release Mark "X" in this block only if this document is used as a Policy Release (policy not attached). Witness When this document is used as a Policy Release, an insured should have a witness sign and date the form before returning it to the agent. Signature of Named Insured First named insured must sign and date this form when used as either a Cancellation Request or Policy Release. Additional Interest Provide the name and address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking "X" in the appropriate box. The signature and title of an authorized representative of any additional interest indicated in the contract must be obtained if the document is used as a Policy Release. Space is provided for the corresponding signature date. FOR AGENCY/COMPANY USE Reason for Cancellation Mark "X" in the appropriate block to indicate the reason for cancellation of the policy. Available options are: Not Taken Request of Insured Rewritten (complete below) Other (Identify) If Rewritten is indicated, enter the new Company, Policy Number, and Inception Date in the spaces provided. If Other is indicated, identify the reason in the space provided. Company The name of the company that the rewritten policy has been placed with. Policy Number The new policy number for the rewritten policy. Effective Date The effective date of the rewritten policy. Method of Cancellation Mark "X" in the appropriate box indicating method of cancellation. Available options are: Flat Short Rate Pro Rata Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. Full Term Premium Premium for the full term (six months, annual, etc.) of the policy, including endorsements. Unearned Factor Unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to date of policy expiration. Return Premium Gross return premium equals the unearned factor multiplied by the full term premium. REMARKS List any additional comments regarding the cancellation. Explanations should be made regarding back-dated cancellations or why premium is listed as being pro-rated instead of short-rated. NAME AND ADDRESS - Request/ Release Distribution Use these sections to list any additional distributions for this form, including the new agent of record, if any. Check the appropriate box for the corresponding address. The line within the name and address field is a margin setting used for window envelopes.

PRODUCER'S SIGNATURE This form should be signed by the agent completing it.

Certificate of Liability Insurance 25-N (1/95)

ACORD 25-N is used for risks containing commercial liability coverages not using the ISO policy simplification format. All other risks should use ACORD 25-S. The instructions within this chapter contain information for completing data within the Coverages section that differs from that on ACORD 25-S. For instructions on the additional sections of this form and general information on using ACORD Certificate of Liability Insurance, refer to the chapter on ACORD 25-S. COVERAGES All limits are to be listed as whole dollar amounts. GENERAL LIABILITY Complete this section if you are certifying general liability coverage. Type of Insurance Indicators Check the appropriate box for the coverages listed on the insured's policy. Available coverage options are: Form Premises Operations Underground, Explosion & Collapse Products & Completed Operations Contractual Independent Contractors Broad Form Property Damage Personal Injury Limits All limits should be listed as whole dollar amounts. Enter the limits as they appear on the policy declarations page. For split limits, use the Bodily Injury Occurrence, Bodily Injury Aggregate, Property Damage Occurrence, and Property Damage Aggregate fields. For combined limits use the BI & PD Occurrence and BI & PD Aggregate fields. See the chapter on ACORD 25-S for other coverage sections and general information on completing Certificates of Liability Insurance.

Certificate of Liability Insurance 25-S (8/2001)

The Certificate of Insurance ACORD 25 is "issued as a matter of information only, and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by policies". The above information is included in the opening statement of the form. If the receiver of the form wants to verify that liability coverage exists on a policy and has no direct interest in the policy, use the certificate of insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as an additional insured, the liability policy must be amended by endorsement, to provide the appropriate coverage for the interested party prior to issuing a certificate of insurance (since the certificate confers no rights upon the holder and does not amend the policy). ACORD 25 was designed to collect policy limit information based on the ISO commercial lines program . It addresses both Claims Made and Occurrence policies. Purpose of the Certificate of Liability Insurance The purpose of the Certificate of Liability has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder. In 1974, the Court of Appeals, Fifth District ruled that a certificate is not a contract between the holder and the insurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration." Although many companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract. Agents or brokers should not change any provision on this form without prior consent of the issuing company. The Certificate of Kiability Insurance is used for most casualty situations in which the insured has requested certification to

a third party of issued casualty coverages.. The uses of the Certificate can include large and small contracting or manufacturing risks, lessor/lessee agreements, or other areas of liability certification. The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the following situations: · To waive rights · To provide information to the owner of a leased motor vehicle or the lender about both liability and physical damage coverages applying to the vehicle (ACORD 23, Leased Auto Certificate of Insurance, should be used for this) · To quote wording from a contract · To attach to an endorsement · To quote any wording which amends a policy unless the policy itself has been amended IMPORTANT Kentucky, Minnesota, North Carolina and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Department of Insurance. Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. IDENTIFICATION SECTION Date Month/day/year which the form is completed. INSURERS AFFORDING COVERAGE Insurer Letter A through E This section is designed for use in certifying coverage issued by many as five companies. Enter only full legal company name(s) as found in the file copy of the policy. Do not enter group or trade names. NAIC No. Enter the NAIC number for each insurer affording coverage. COVERAGES Insr Ltr Enter the Insurer Letter, as identified in the Insurers Affording Coverage section, next to the appropriate coverage(s). Add'l Insrd Use this column if the certificate holder has been named as an additional insured for any of the coverages described in the certificate. Place a check mark next to each coverage where an additional insured endorsement has been issued. Policy Number Show the number exactly as it appears on the policy, including prefix and suffix symbols for each "Type of Insurance". Policy Effective Date Date on which the terms of the policy commenced. Policy Expiration Date Date on which the terms and conditions of the policy expire. Limits All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Abbreviations: Med. Exp. . . . . . . . . . . . . . . . Medical Expense Personal & Adv. Injury . . . . . . . Personal and Advertising Injury Products-Comp/Op Agg . . . . . . Products and Completed Operations Aggregate General Liability

Complete this section if you are certifying general liability coverage. Commercial General Liability Check this box for Commercial General Liability (CGL) and one of the corresponding boxes to designate the type of policy issued, Claims Made, or Occurrence (Occur) of CGL policy. Other General Liability Coverages The two open option boxes available allow listing of liability coverages not found on this form. List the coverage type next to the available box. An example of this would be issuing a certificate for Comprehensive Personal Liability. The first box would be checked and "Comprehensive Personal Liability" would be inserted on the line after the box. General Aggregate Limit Applies Per Check the appropriate box to indicate if the general aggregate limit applies per policy, per project, or per location. Automobile Liability Complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. The last available option box allows listing an automobile liability coverage not found on this form. List the coverage type next to this optional box. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Leased Auto Certificate of Insurance. Garage Liability Complete this section only if you are certifying garage liability. Use the available lines or the "Any Auto" option to indicate coverage specifics. Excess/Umbrella Liability Complete this section only if you are certifying some type of excess or umbrella liability policy. Check the appropriate box to indicate whether the "coverage trigger" is on a claims-made or an occurrence basis. Also show any deductible or retention amount. Workers Compensation and Employers' Liability If workers compensation coverage is based on statutory limits, check the appropriate box within the limit section. If other limits apply, check the appropriate box and show the limits in the "Other" section. If Employer's Liability is to be certified, show the limits applicable to "Each Accident", "Disease-Each Employee" and "Disease-Policy Limit". Other This section certifies other coverages that are not listed on the form. The type of insurance, policy number, policy effective date, policy expiration date and limits sections should be completed. Description of Operations/Locations/Vehicles/Exclusions Added by Endorsement/Special Provisions Record information necessary to identify the operations, locations or vehicles for which the certificate was issued. Any exclusion endorsement or special policy conditions should also be indicated. Information about additional insureds should also be shown here. However, if it is necessary to show several additional insureds for liability coverages (e.g., mortgagees, vendors, landlords, etc.), and there is not enough room on the form, use the Descriptions box to indicate "see Additional Interest form, ACORD 45, attached" and use ACORD 45 to show the information pertinent to the additional insureds. Certificate Holder Name and mailing address of the individual or entity for whom the certificate is being prepared. The line within this field is a margin setting for window envelopes. Cancellation Number of days in which the company will endeavor to mail a written cancellation notice. This amount is subject to approval by the company(ies). Authorized Representative Form must be signed by an agent, broker, or other representative authorized by all companies to issue Certificates.

Certificate of Property Insurance 24 (1/95)

Certificate of Property Insurance vs. Evidence of Property Insurance An important distinction exists between the Certificate of Property Insurance (ACORD 24) and the Evidence of Property Insurance (ACORD 27). This distinction is outlined in the opening statements of each form. Certificate of Property Insurance

This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. It does not amend, extend, or alter the coverage afforded by the policies below. Evidence of Property Insurance This is evidence that insurance as identified below has been issued, is in force, and conveys all the rights and privileges afforded under the policy. If the receiver of the form wants to verify that property insurance coverage exists on a policy and has no direct interest in the policy, use the Certificate of Property Insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as a mortgagee or additional insured, use the Evidence of Property Insurance. Purpose of the Certificate of Insurance The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder. This is particularly important when the difference between a certificate holder and lien holder, loss payee, or mortgagee is considered. In 1974, the Court of Appeals, Fifth District ruled that a certificate is not a contract between the holder and the insurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration." Although most companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract. Agents or brokers should not change any provisions on this form without prior consent of the issuing company. The Certificate of Property Insurance is used for most property situations in which the insured has requested certification of issued property coverages to a third party. The uses of this Certificate can include parties involved in condominium association agreements, lessor/lessee agreements, or other areas of certification. The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the following situations: To satisfy a mortgagee or lienholder (the Evidence of Property Insurance (ACORD 27) should be used for this) To quote wording from a contract To waive rights To attach to an endorsement To quote any wording which amends a policy unless the policy itself has been amended. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Name, address and phone number of the producer or broker issuing this form. Insured Insured's name and address as they appear on the policy declarations page. The line within this field is a margin setting for window envelopes. COMPANIES AFFORDING COVERAGE Company Letter A Through D This section is designed for use in certifying coverage issued by as many as four companies. Enter only full legal company name(s) as found on the file copy of the policy. Do not enter group or trade names. COVERAGES Co Ltr Enter the Company Letter of the company, as identified in the Companies Affording Coverage section, next to the appropriate coverage(s). Type of Insurance Check the appropriate box(es) to indicate the coverage afforded by the policy. For Inland Marine, describe the type of policy (e.g., Equipment Floater, EDP, etc.). Also, check the appropriate box to indicate if "Named Perils" or "Other" causes of loss apply. If necessary, describe under "Special Conditions/Other Coverages". If crime coverage applies, describe the type of policy (e.g., Forgery, Money and Securities, Premises Safe, etc.). Policy Number Show the number exactly as it appears on the policy, including prefix and suffix symbols for each "Type of Insurance". Policy Effective Date Date on which the terms and conditions of the policy commenced. Policy Expiration Date Date on which the terms and conditions of the policy expire. Covered Property Describe the property covered. Limits All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page.

LOCATION OF PREMISES Location/Description For buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave, Endicott - Grocery Store with Apartments, or Route 66, five miles south of intersection with I99 - Tobacco Barn). For other property items, such as inland marine equipment (for lessor information), describe the item along with any available vehicle identification number or serial number (e.g., 82 Case Backhoe Model H-15, Ser # G5963a57). SPECIAL CONDITIONS/OTHER COVERAGES Record any special policy conditions or coverages not fully explained in the Coverages section. Certificate Holder Name and mailing address of the individual or entity for whom the certificate is being prepared. The line within this field is a margin setting for window envelopes. Cancellation Number of days in which the company will endeavor to mail a written cancellation notice. This amount is subject to approval by the company(ies). Authorized Representative Form must be signed by an agent, broker, or other representative authorized by all companies to issue Certificates.

Commercial Auto 137

Alabama Commercial Auto, Coverages/Limits Section ACORD 137 AL (6/2001) Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. Alaska Commercial Auto, Coverages/Limits Section ACORD 137 AK (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132 Truckers/Motor Carrier Section. This following are the specific differences in this state: · Personal Injury Protection coverage does not apply; this is not a "no-fault" state. · A required statement has been added to the back of the form with respect to the offer of Rental Vehicle Damage coverage if Comprehensive and/or Collision coverage has been rejected by the applicant. Arizona Commercial Auto, Coverages/Limits Section ACORD 137 AZ (7/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section or ACORD 132, Truckers /Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverage is not available; this is not a "no-fault" · state. · Uninsured and Underinsured Motorists Property Damage coverages are not · available. · Statement added to the back of the form, referencing the Arizona Supplement, · ACORD 61 AZ, which must be signed by the applicant. Arkansas Commercial Auto, Coverages/Limits Section ACORD 137 AR (10/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. The following are the specific differences in this state. Personal Injury Protection coverages are revised to reflect unique Arkansas coverages and options. Refer to your state manual. Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorist Property Damage is not available. An additional statement is added, referencing the Arkansas Supplement, ACORD 61 AR, which must be used if the applicant chooses Uninsured or Underinsured Motorists Bodily Injury coverages less than the limits of the policy's basic Bodily Injury Liability limits. A statement is added to the back of the form allowing the applicant to reflect any or all of the Personal Injury Protection coverages.

California Commercial Auto, Coverages/Limits Section ACORD 137 CA (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage does not apply. This is not a "no-fault" state. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · Reference to "Waiver of Collision Deductible" is added. · Statement added referring to the offer of Uninsured Motorists coverage up to · the Bodily Injury Liability coverage in the policy, and the applicant's right to · select lower limits, reject coverage for certain drivers, or reject UM coverage · entirely. If the applicant chooses any option other than limits equal to the · policy's BI limits, the California Auto Supplement, ACORD 61 CA, must be · signed. · Statement added referring to the offering of a Waiver of the Collision deductible. · The fraud statement is revised to comply with California law. · A statement is added to the back of the form as required by California law, · advising the applicant of his or her rights with respect to "good driver" policies. Colorado Commercial Auto, Coverages/Limits Section ACORD 137 CO (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Personal Injury Protection coverages are replaced with Colorado's unique coverages and options. Refer to your state manual. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · The fraud warning is specific to the state. · Statement added referring to the explanation and offer to the applicant of Uninsured Motorists coverage, and the right of the applicant to select/reject coverage. If Uninsured Motorists Bodily Injury coverage is rejected entirely, the applicant must initial the statement. Connecticut Commercial Auto, Coverages/Limits Section ACORD 137 CT (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Personal Injury Protection coverages reflects the optional coverages available. · Uninsured Motorists and Underinsured Motorists coverages are combined. · Uninsured Motorists Conversion coverage is added. This coverage can be purchased instead of Uninsured/Underinsured Motorists coverage. Delaware Commercial Auto, Coverages/Limits Section ACORD 137 DE (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance inthis state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. Following are the specific differences in this state. · Personal Injury Protection coverages are revised to reflect Delaware's unique coverages and options. Refer to your state manual. · Underinsured Motorists Bodily Injury coverage is included in Uninsured Motorists coverage; Property Damage coverage is not available. · Statement added to the back of the form, referencing the auto supplement, ACORD 61 DE, which must be used whenever the applicant chooses Uninsured Motorists Bodily Injury coverage less than the limits of the policy's basic Bodily Injury Liability limits, or rejects · coverage entirely. District of Columbia Commercial Auto, Coverages/Limits Section ACORD 137 DC (9/2000)

Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state. Personal Injury Protection coverages reflect Delaware's unique coverages and options. Refer to your state manual. Statement added referencing the offer of Uninsured and Underinsured Motorists coverages, and the applicant's right to select coverage limits, and reject Underinsured Motorists coverage. Statement added allowing the applicant to reject Personal Injury Protection coverages. Applicant must signify rejection by initialing the form. Fraud warning specific to DC. Florida Commercial Auto, Coverages/Limits Section ACORD 137 FL (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. The following are the specific differences in this state. Personal Injury Protection coverages reflect Florida's unique coverages and options. Refer to your state manual. Underinsured Motorists /Bodily Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form referencing the various Uninsured Motorists coverage options, and the use of the state supplement, ACORD 61 FL, if Uninsured Motorists, or non-stacked coverage, is rejected. Georgia Commercial Auto, Coverages/Limits Section ACORD 137 GA (2/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Personal Injury Protection coverage does not apply; this is not a "not-fault" state. · Uninsured Motorists coverage includes Underinsured Motorists coverage; provision is made for per-accident deductibles under Uninsured Motorists coverage. · A required statement has been added to the back of the form referring to the state supplement containing explanation and selection options for Uninsured Motorists. Hawaii Commercial Auto, Coverages/Limits Section ACORD 137 HI (2/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. · · Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Uniques Personal Injury Protection and Additional Personal Injury Protection items are provided. · The applicant can select "stacked" or "non-stacked" Uninsured and · Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available. · A state-specific fraud warning is included on the back of the form. Idaho Commercial Auto, Coverages/Limits Section ACORD 137 ID (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverages are not available; this is not a "no-fault" state. · Uninsured and Underinsured Motorist Property Damage coverages are not available. · Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits, and the applicant's right to select other limits, or to reject coverage entirely. Illinois Commercial Auto, Coverages/Limits Section ACORD 137 IL (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Personal Injury Protection coverages are not available; this is not a (no-fault) state. · Uninsured and Underinsured Motorist Bodily injury coverages are combined; Underinsured Motorists Property Damage coverage does not apply; Uninsured Motorists Property Damage coverage is shown separately. · Statement added referring to the state supplement, ACORD 61 IL, with respect to the selection of Uninsured/Underinsured Motorists Bodily Injury Liability coverage lower than the Bodily Injury Liability coverage

in the policy, or the selection of Uninsured Motorists Property Damage coverage for vehicles not covered by collision insurance. Indiana Commercial Auto, Coverages/Limits Section ACORD 137 IN (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury and Property Damage coverages. The applicant must initial the statement if any coverage is rejected. Iowa Commercial Auto, Coverages/Limits Section ACORD 137 IA (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/ Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured Motorists and Underinsured Motorists coverage sections include reference to "stacked" and "non-stacked" coverages; Uninsured and underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the state supplement, ACORD 61 IA, the offer of various Uninsured and Underinsured Motorists Bodily Injury coverage options, and the applicant's right to select or to reject coverage entirely. If the insured decides to select "stacked" UM or UIM, or to reject either UM or UIM coverage, the state supplement must be signed. A state-specific privacy notice is added. Kansas Commercial Auto, Coverages/Limits Section ACORD 137 KS (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state. Personal Injury Protection coverages have been revised to allow for Kansas options. Refer to your state manual. Uninsured Motorists coverage includes Underinsured Motorists coverage; however, there is no property damage coverage available. A required statement has been added to the back of the form, advising the applicant that auto liability insurance may be available through the Kansas Automobile Insurance Plan. In addition, a statement has been added to the back of the form requiring the applicant to acknowledge available Uninsured Motorists coverage options, including the option of rejecting UM limits higher than the mandatory minimum limits. Kentucky Commercial Auto, Coverages/Limits Section ACORD 137 KY (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state. Provision is made to report the "Tax Territory", as required by Kentucky law. Personal Injury Protection coverages are revised to reflect Kentucky's unique coverages and options. Refer to you state manual. Uninsured and Underinsured Motorists Property Damage coverage are not available. Added section to the back of the form to allow descriptions of motorcycles, and named individuals to be covered, as required under PIP options. Provided statement referencing the explanation to the applicant of Uninsured and Underinsured Motorists coverages and available options; provided space to allow the applicant to reject UM and/or UIM. The fraud statement on the back of the form is revised to reflect Kentucky law. Louisiana Commercial Auto, Coverages/Limits Section ACORD 137 LA (6/98) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorist coverage. Statement added to the back of the form, referencing the offer of Uninsured Motorists coverages up to the policy's basic Liability limits, and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option(s) selected. Maine Commercial Auto, Coverages/Limits Section ACORD 137 ME (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. The following are the specific differences in this state.

Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Bodily Injury coverages are combined. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits and the applicant's right to select lower limits, or to reject coverage entirely. A state-specific fraud warning is added to the back of the form. Maryland Commercial Auto, Coverages/Limits Section ACORD 137 MD (6/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverages are revised to reflect Maryland's unique coverages and options. Refer to your state manual. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · Statement added to the back of the form, referencing the state supplement, ACORD 62 MD, which must be given to the applicant if Personal Injury Protection coverage is rejected, or if Uninsured Motorists' Bodily Injury coverage less than the limits of the policy's Bodily Injury Liability limits is selected. Michigan Commercial Auto, Coverages/Limits Section ACORD 137 MI (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. The following are the specific differences in this state. Additional Property Damage Liability coverage in the amount of $400.00 is a basic liability coverage option. Personal Injury Protection coverages have been revised to allow for unique Michigan coverages and options. Refer to your state manual. No property damage coverage is available under Uninsured or Underinsured Motorists. Several collision options are shown. Refer to your state manual. Provision is made to allow individuals covered under the policy who are 60 years of age or older, and who have no expectation of actual income loss in the event of an accident, to reject coverage for work loss under Personal Injury Protection coverage. Each individual eligible must the application. A statement is added referencing the Michigan Collision Insurance Options Notice (ACORD 62 MI) which must be given to every applicant for auto insurance in Michigan. A statement is added that provides the address and phone number of the Michigan Insurance Bureau. Minnesota Commercial Auto, Coverages/Limits Section ACORD 137 MN (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. The following are the specific differences in this state. The Personal Injury Protection items revised to reflect Minnesota's unique coverages. A statement is added requiring the applicant to acknowledge receipt of a copy of the Minnesota Guaranty Association Notice ( ACORD 65 MN). A statement is added requiring the applicant to acknowledge the offering of Uninsured/Underinsured Motorists coverage up to the limits of BI Liability. A statement is added referencing the company's right to cancel coverage during the forty-nine days following the issuance of coverage, for any reason not prohibited by law. The fraud statement on the back of the form is revised to reflect a new Minnesota law. Mississippi Commercial Auto, Coverages/Limits Section ACORD 137 MS (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists coverages are combined. Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists coverages up to the limits of the policy's Liability limits, and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected. Missouri Commercial Auto, Coverages/Limits Section ACORD 137 MO (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage does not apply; this is not a "no-fault" state. Uninsured and Underinsured Motorist Property Damage coverages are not available. A required statement has been added to the back of the form, indicating that the premium quoted is an estimate only, and that premium charged will be in accordance with the company's filed rates. A statement has been added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists coverage. Montana Commercial Auto, Coverages/Limits Section ACORD 137 MT (8/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Uninsured Motorist Property Damage and Underinsured Motorists Property Damage coverages are not available. A statement has been added to the back of the form, referencing the offering of Uninsured Motorists coverage up to the limits of Bodily Injury liability coverage, and the applicants right to reject coverage. A state-specific privacy notice is added. Nebraska Commercial Auto, Coverages/Limits Section ACORD 137 NE (8/97) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. The Fraud statement is removed. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the limits of the policy's Bodily injury Liability Limits and the applicant's right to select lower limits or reject coverage entirely. Nevada Commercial Auto, Coverages/Limits Section ACORD 137 NV (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Provision is made in the "Applicant" box at the top of the front of the form to record the applicant's Federal Employer ID Number (FEIN), as required by Nevada statutes and regulations. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured Motorists Bodily Injury coverage is included in Uninsured Motorists Bodily injury coverage. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the state supplement, ACORD 61 NV, which must be given to the applicant to explain the available options under Medical Payments and Uninsured Motorists coverage. New Hampshire Commercial Auto, Coverages/Limits Section ACORD 137 NH (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. New Jersey Commercial Auto, Coverages/Limits Section ACORD 137 NJ (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages have been revised to provide for unique New Jersey coverages. Refer to your state Manual. Uninsured and Underinsured Motorists coverages are combined. Comprehensive is changed to "other than collision coverage". The fraud statement on the back of the form is revised to comply with New Jersey law. A statement has been added referencing the offer of Uninsured/Underinsured Motorists coverage up to the policy's BI limits. New Mexico Commercial Auto, Coverages/Limits Section ACORD 137 NM (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage

coverages up to the limits of the policy's Liability limits and the applicants right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected. New York Commercial Auto, Coverages/Limits Section ACORD 137 NY (4/98) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are revised to reflect New York's unique coverages and options. Refer to your state Manual. Uninsured and Underinsured Motorists coverages are replaced by "Statutory UM" and "Supplemental UM (SUM)". Refer to your state Manual. Fraud statement is replaced with New York's Fraud Statement language. Statement added to the back of the form referencing the availability of Statutory Uninsured Motorists and Supplementary Uninsured Motorists coverages and options. North Carolina Commercial Auto, Coverages/Limits Section ACORD 137 NC (5/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · A box relating to "facility Code" is added to the front of the form, to provide information relating to the reinsurance facility. · Personal injury Protection coverage is not available; this is not a "no-fault" state. · Provision is made for combined Uninsured/Underinsured Motorists Bodily Injury coverage, and separately for Uninsured Motorists coverage. Underinsured Motorists Bodily Injury coverage is not available by itself. · An instruction is added requiring the fire district name and code number if fire or comprehensive coverage is provided. · Statement added to the back of the form to allow the applicant to select or reject the various Uninsured and Underinsured Motorists coverage options. The applicant must initial the selection(s). North Dakota Commercial Auto, Coverages/Limits Section ACORD 137 ND (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages revised to reflect North Dakota's unique coverages and options. Refer to your state Manual. Uninsured and Underinsured Motorists Bodily Injury coverages are combined; Uninsured/Underinsured Motorists Property Damage coverages are not available. Statement is added to the back of the form to allow the applicant to reject Additional Personal Injury protection coverage. The applicant must initial the form. Ohio Commercial Auto, Coverages/Limits Section ACORD 137 OH (4/98) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection is not available. This is not a "no-fault" state · Underinsured Motorists coverage is included in Uninsured Motorists coverage · Provision is made for Uninsured Motorists Property Damage coverage · The Fraud Statement is revised to comply with Ohio law · A statement has been added to the back of the form referring to the Uninsured Motorists coverage state supplement. Oklahoma Commercial Auto, Coverages/Limits Section ACORD 137 OK (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Underinsured Motorists BI coverage is included in Uninsured Motorists coverage; Property Damage coverage is not available. The fraud statement is revised to comply with Oklahoma law. Oregon Commercial Auto, Coverages/Limits Section ACORD 137 OR (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are revised to reflect Oregon's unique coverages and options. Refer to your state Manual.

Underinsured Motorists coverage is included in Uninsured Motorists coverage. Statement added to the back of the form, referring to the state supplement, ACORD 61 OR, which must be given to the applicant to explain Uninsured Motorists coverage, and the options available. Pennsylvania Commercial Auto, Coverages/Limits Section ACORD 137 PA (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage sections have been revised in accordance with unique Pennsylvania coverages and options. Refer to your State Manual. Provided for the selection of "stacked" or "non-stacked" coverage under Uninsured and Underinsured Motorists BI coverages. Property Damage coverage is not available. The Fraud Statement is revised to comply with Pennsylvania law. Rhode Island Commercial Auto, Coverages/Limits Section ACORD 137 RI (3/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. · The following are the specific differences in this state: · Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorist coverages are combined. · Statements are added to the back of the form that: 1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected; 2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if Uninsured/Underinsured Motorists Bodily Injury coverage is rejected; 3. Allow the applicant to acknowledge the offer of Uninsured/Underinsured Motorists Property Damage coverage, and the options selected. · The applicant must initial the options selected. South Carolina Commercial Auto, Coverages/Limits Section ACORD 137 SC (4/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · A box relating to "Facility Code" is added to the front of the form, to provide information relating to the reinsurance facility. · Medical Payments coverage is deleted; Medical expenses are included under Personal Injury Protection coverage. South Dakota Commercial Auto, Coverages/Limits Section ACORD 137 SD (2/97) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this State. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are revised to reflect South Dakota's unique coverages and options. Refer to your State Manual. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form to allow the applicant to select or reject supplemental auto coverage. The applicant must initial the form. Tennessee Commercial Auto, Coverages/Limits Section ACORD 137 TN (11/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. · Personal Injury Protection coverages are not available; this is not a "no-fault" state. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage coverages up to the limits of the policy's Liability limits and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option(s) selected. Texas Commercial Auto, Coverages/Limits Section ACORD 137 TX (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor

Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are revised to provide for various Texas coverages and options. Refer to your State Manual. Uninsured and Underinsured Motorists coverages are combined. The Property Damage deductible is $250.00. Statements are added to the back of the form requiring the applicant to acknowledge the explanation of Uninsured/Underinsured Motorists coverage and Personal Injury Protection, and to acknowledge selection/rejection decisions by initialing the statements. Utah Commercial Auto, Coverages/Limits Section ACORD 137 UT (1/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverages reflect the unique coverages available in this state. · Underinsured Motorists Property Damage coverage is not available. · A statement is added to the back of the form explaining arbitration as an alternative to court action. This statement is required by Utah law. Vermont Commercial Auto, Coverages/Limits Section ACORD 137 VT (1/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverage is not available; this is not a "no-fault" state. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · The Fair Credit Reporting Act Statement is replaced with Vermont's Fair Credit law requirements. · A statement is added to the back of the form, referencing the explanation of Uninsured Motorists coverage to the applicant, and the applicant's selection of coverage. · The fraud warning complies with VT law. Virginia Commercial Auto, Coverages/Limits Section ACORD 137 VA (8/2001) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state: · Personal Injury Protection coverage is revised to reflect the coverages and options available in Virginia. Refer to your state Manual. · Underinsured Motorists coverage is included in Uninsured Motorists coverage. · A required statement is added referring to the Company's right to cancel the policy for any reason within the first 60 days it is in effect, and thereafter for reason stated in the policy. · A statement is added referencing the offering of Uninsured Motorists coverage. · Dual lines are provided for the initials of more than one named insured at the end of the statement on the back of the form relating to Uninsured Motorists coverage selection. A recent court decision determined that each named insured must acknowledge the offer of UM coverage. · A state-specific fraud warning and privacy notice are added. Washington Commercial Auto, Coverages/Limits Section ACORD 137 WA (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage is revised to reflect Washington's unique coverages and options. Refer to your state Manual. Added "Auto Loan" coverage in the Coverages/Premium section. Statement added to the back of the form referring to the options available under Underinsured Motorists and Personal Injury Protection coverages and the applicant's right to reject these coverages. West Virginia Commercial Auto, Coverages/Limits Section ACORD 137 WV (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the state supplements, ACORD 60 WV, 61 WV, and 62 WV, with

respect to the offering and selection of Uninsured and Underinsured Motorists coverages. Wisconsin Commercial Auto, Coverages/Limits Section ACORD 137 WI (3/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statements added to the back of the form: 1. Acknowledging the offer of Medical Payments coverage, and allowing the applicant to reject this coverage; the applicant must initial the form of coverage that is rejected. 2. Acknowledging the offer of Uninsured and Underinsured Motorists Bodily Injury coverage, and the options available. Wyoming Commercial Auto, Coverages/Limits Section ACORD 137 WY (1/96) Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverage is not available. A statement is added to the back of the form referencing the offering of Uninsured and Underinsured Motorists coverage. A statement is added advising the applicant that, if a loss occurs to an insured vehicle and the insured is paid for that loss but doesn't actually repair the vehicle, any subsequent losses will be paid with the cost of the damage associated with prior losses being deducted.

Commercial General Liability Section 126-S (4/2000)

Commercial General Liability is a form of insurance designed to protect owners and operators of businesses from a wide variety of liability exposures. These exposures include liability for accidents resulting from the insured's operations or premises, products sold or operations completed by the insured, and contractual liability. The Coverage and Limits Section of the ACORD 126-S was designed to follow the ISO Policy Simplification Program first initiated in 1986. To request General Liability coverage from companies not following this format please refer to the ACORD 126-N. The ACORD 126-S was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Please refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Much of the information for the Identification Section should match that found within the Applicant Information Section of ACORD 125. Even so, it is still important to complete this section. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name and address. Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date

Month/day/year on which the terms and conditions of the policy will commence. Expiration Date Month/day/year on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Plan used to pay the company for the policy. Use the company's specific designation for the plan where possible. (E.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30.) Audit The term for policies that are subject to periodic audit. If the audit period is known, enter the code: A = annual S = semi-annual Q = quarterly M = monthly O = other COVERAGES Commercial General Liability Indicate if commercial general liability coverage is required. Claims Made Check to request that the Commercial General Liability policy be issued on a claims made basis. For Claims Made policies, be sure to complete the Claims Made section of the application. Occurrence Check to request the Commercial General Liability policy be issued on an occurrence basis. Owner's & Contractors Protective Check only when separate Owner's & Contractors Protective Liability coverage is being requested. * Use the blank area to request other coverage forms such as Railroad Protective Liability, Liquor Liability, Pollution Liability, or a separate Products/Completed Operations Liability Only policy. Deductibles If a deductible is requested, indicate the amount and type of deductible, and whether it is to apply per claim or per occurrence. Use the blank line to indicate options other than Property Damage or Bodily Injury Deductible. Per Claim A per claim deductible applies to individual claims even if the claims are all related to the same occurrence or event. Per Occurrence A per occurrence deductible applies once to each occurrence no matter how many individual claims result from the occurrence or event. Other Coverages, Restrictions, and/or Endorsements Use this area to request any other coverages, endorsements, or special conditions. Examples: Include the Vendors Endorsement Exclude Fire Damage coverage Exclude Medical Expense coverage Exclude Personal and Advertising Injury coverage LIMITS Enter the policy limits as they are to appear on the policy declarations page. Available limits following the ISO Policy Simplification Program are: (All limits are in whole dollars.) General Aggregate Each Occurrence Products & Completed Operations Aggregate Fire Damage (Any One Fire) Personal & Advertising Injury Medical Expense (Any One Person) Employee Benefits Premiums Not all companies require that the producer rate the policy prior to submission of the application. If you have done so, enter the coverage premiums here. SCHEDULE OF HAZARDS Location # For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number.

Classification Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Class Code Provide the general liability class code that corresponds to the class description shown in the previous field. Premium Basis Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (E.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Terr. For each discribed exposure, enter the rating territory code based on location from the appropriate state exception page. Rate - Prem/Ops & Products If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. Premium - Prem/Ops & Products If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. CLAIMS MADE (Explain All "Yes" Responses) If a Claims Made coverage is requested, this section needs to be completed. Use this section to explain the status of previous Claims Made coverage. Because a Claims Made policy uses a different coverage "triggering" mechanism, this additional information is needed to properly process the application. * It is very important that the information in this section be accurate to ensure uninterrupted general liability coverage for the applicant. Use the Comments area to provide additional information. 1. Proposed Retroactive Date The Retroactive Date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could "trigger" coverage under a Claims Made policy. 2. Entry date into uninterrupted claims made coverage The retroactive date shown on the applicant's first Claims Made policy. If this is the first such policy, the date will be the same as the proposed retroactive date shown on the preceding field. If this is a renewal, it is the effective date of the first policy issued in the sequence of uninterrepted Claims Made policies. 3. Has any product, work, accident or location been excluded, uninsured or self-insured from any previous coverage? For yes responses, describe the situations of the above occurrences in the Comment section. 4. Was tail coverage purchased under any previous policy? For yes responses, describe terms and limits of tail coverage purchased under any previous policy. Tail coverage extends the reporting period on a Claims Made policy to cover claims arising from occurrences that were not known by the date the policy was cancelled, non-renewed or replaced. EMPLOYEE BENEFITS LIABILITY Use this section when Employee Benefits Liability is to be provided, to collect information about deductibles, number of employees, number of employees covered by Employee Benefits plans, and retroactive date, if applicable. CONTRACTORS The information requested is for any past or present operations. This is important because the contractor applicant continues to be held responsible for injury or damage that results from completed work done by the contractor, or for it by subcontractors. Use the Remarks area to provide additional information. 1. Does applicant draw plans, designs, or specifications for others? If the applicant draws plans, designs or specifications, explain. Indicate whether qualified professionals are employed by the applicant for preparation. 2. Do any operations include blasting or utilize or store explosive material? Describe any operation that includes any of these activities. 3. Do any operations include evacuation, tunneling, underground work or earth moving? Describe any operation that requires any of these activities and the safety measures taken. 4. Do your subcontractors carry coverages or limits less than yours? State the limits of coverages carried by subcontractors if less than the applicant's. Identify the subcontractors and the amount of coverage.

5. Are subcontractors allowed to work without providing you with Certificates of Insurance? Explain why certificates are not requested from subcontractors. 6. Does applicant lease equipment to others with or without operators? If applicant leases equipment describe the type of equipment, number of operators, frequency, and lease arrangement. Remarks/Describe the type of work & percentage subcontracted Describe in detail the type of work the applicant subcontracts. Also include leased equipment activities. (E.g., An excavation contractor may subcontract the blasting required. This may account for 10% of the contracts it undertakes.) List any other remarks that may be pertinent to the contractors work. $ Paid to Subcontractors Show the total annual dollars paid. % of Work Subcontracted List the total percentage of work that the contractor subcontracts. # Full Time Staff Indicate the total number of full time staff. # Part Time Staff Indicate the total number of part time staff. PRODUCTS/COMPLETED OPERATIONS This section should be completed whenever Products/Completed Operations coverage is being requested by the applicant. While it may seem to be designed with manufacturers in mind, it is also intended to be completed for retail stores, distributors, and contractors. Products Use this field to describe the products for which product liability coverage is being requested. The description should be detailed enough so that the underwriter can fully understand the nature of each product. If there are too many products to describe individually, those which share certain characteristics should be grouped under a single generic description and the characteristics of each group should be described. Attach any literature or brochures available. (E.g., All of the furniture manufacturer's office desks can be described as "office desks", because each one is very similar to the other, even though there are several sizes and shapes and they are designed for home or office use. On the other hand, dining tables and medical office patient examination tables should not be grouped as "tables" because they are dissimilar in design and function.) Annual Gross Sales Estimated dollar amount the applicant expects to sell in the coming year for each product or product group described. Remember the application is for the next policy year, not the current or past policy year. An amount should be shown for each product or product group described. This breakdown of sales is primarily needed to figure the premium, especially when there are two or more products and each one is subject to a different rating classification. # of Units Number of units the applicant expects to sell and/or manufacture in the coming year. An amount should be shown for each product or product group described. The breakdown of units is primarily needed to estimate the product's claims frequency potential. Time in Market Number of years or months that each described product or product group has been sold by the applicant. Expected Life Average length of time, (days, weeks, months, or years) that the applicant expects each described product or group of products to last until it is worn out, used up, or consumed. This may be the shelf life for products consumed or useful life for other products. Intended Use Describe the use or uses of each product or product group contemplated by the applicant. The following information should be provided: What the product is designed to be or do How the product is designed to work or function How, when and where the product is designed to be used or consumed Example: If the product is food, its use is apparent. If it is a chemical or a machine part, there may be a variety of uses. In these instances, the specific use becomes an important consideration for both coverage and pricing. This information is necessary for the underwriter to identify and evaluate the hazards associated with the use or potential misuse of a product. Principal Components Major components of the product. If additional space is needed to complete the information required for a particular

product, attach a separate sheet. Use the Remarks section or a separate sheet of paper to explain any "Yes" responses to the following questions, for any past or present operation or product. 1. Does applicant install, service or demonstrate products? The explanation of a "Yes" response to this question should include: What, how and where it is done Who does it, employees or independent contractors Whether a maintenance or repair service is sold When the work is done by independent contractors, the explanation should also include information on the cost of the work done for the applicant by the independent contractors. 2. Foreign products sold, distributed, or used as components? Each foreign-made product or product group bought, sold or distributed by the applicant should be described. In addition, the following information should be provided on each described product or group of products: Intended use Expected use life Time in the market Principal components Estimated annual gross sales Major source, such as U.S.-based importer or foreign-based exporter or manufacturer Relationship with manufacturer or exporter The explanation should also indicate, for each major source, whether or not that source has U.S. products liability insurance, the limits of that insurance, and the name of the domestic insurer. Indicate whether the applicant markets products abroad. 3. Research and development conducted or new products planned? Describe the nature and extent of R&D work. Example: Indicate if it is solely directed at the development of new products or if some effort is directed to improving or changing existing products. Describe any new products to be marketed within the next 12 months and the potential market. Provide an estimate of anticipated sales. 4. Guarantees, warranties, hold harmless agreements? A guarantee is a promise made by the seller that the product can be returned for repair, replacement or a refund if the buyer is unsatisfied with it for some reason. A warranty is a positive statement that the product is as represented or will be as promised by the seller. If the applicant issues written guarantees or warranties with its products, copies should be attached. Indicate whether they have been reviewed by an attorney. The presence of a Hold Harmless agreement means that the applicant has assumed certain obligations or liabilities of another person or firm. Remember, the contractual liability coverage contained in the Commercial General Liability coverage form applies only to covered bodily injury and property damage for which the indemnitee (the person or firm being held harmless) is liable in tort. Coverage does not apply to any other obligation or liability that the applicant may have assumed in the Hold Harmless agreement. Attach copies of any Hold Harmless agreements the applicant may have signed. 5. Products related to aircraft/space industry? Describe any aircraft or space industry products sold or installed by the applicant and explain how and by whom they are used. Many insurers have underwriting restrictions on aerospace related products. (E.g., electronic equipment, aircraft frames, guided missile systems.) 6. Products recalled, discontinued, changed? The applicant's current products liability exposure includes products that are still in use but may not have been found and fixed by a recall, products no longer made, and products made prior to a product change. These exposures must be separately underwritten when such products are known to exist. A product recall usually indicates that the products subject to the recall were considered to be unreasonably dangerous. Consequently, any product recall should be fully explained. The explanation provided for recalled products should include the following: A description of the products including their intended use and expected life The reason for the recall, including a description of the product defects, if any, which made the recall necessary Who initiated the recall, the applicant or a government agency The purpose of the recall, modification, repair or replacement of the defective products, and the effectiveness of the recall A description of the recall method The total number of the defective products subject to the recall The result of the recall, including the percentage of recalled products found The explanation provided for discontinued products should indicate when and why manufacturing ended and how many items are estimated to be in current use. A changed product may forecast a start of or increase in claims or suits from the products made before the change. The explanation should indicate when the change was made and the reason for the change.

7. Products of others sold or repackaged under applicant's label? When the applicant sells products under its name or label that are made by someone else, the applicant should be considered as the manufacturer of those products. Indicate whether products are repackaged, modified, or further processed by applicant. The explanation should include information on who supplies the products and the contractual relationship between the applicant and the actual manufacturer. 8. Products under label of others? When the applicant makes products that are sold with someone else's name or label on them, the explanation should provide the following information: Who has contracted for the products and who is selling them? Are the products processed further by others before reaching the ultimate consumer? 9. Vendor's coverage required? The explanation should identify the vendor, explain why the vendor wants to be included as an additional insured, and indicate the extent of coverage required by the vendor. Provide the gross sales to each vendor. 10. Does any named insured sell to any other named insured? Provide the product(s) name. All sales of products between multiple named insureds must be included when determining the total gross sales used for premium computations. Please attach literature, brochures, labels, warnings, etc. ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the general liability portion of this policy. For additional names attach an ACORD 45, and check the box in the title line of this section. Interest Indicate all appropriate options for the individual named. Rank Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee. Name and Address List the additional interests name and address. Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number. Certificate Required If a Certificate of Insurance is required check this box. Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured. Item Description If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the Remarks section for "Yes" responses. 1. Any medical facilities provided or medical professionals employed or contracted? Describe the medical or first aid facilities provided on the premises. Indicate if any physicians or other health care personnel are employed or contracted. 2. Any exposure to radioactive/nuclear materials? Indicate if the applicant's operating/manufacturing process involves the use of or deals with these materials. Is a Nuclear Regulatory (Atomic Energy) Commission license required? 3. Do operations involve storing, treating, discharging, applying, disposing or transporting hazardous material? Indicate whether the applicant's operations involve any discharge of fumes, acids, caustics, or wastes. List any harmful by-products generated and how they are controlled, stored or disposed of. Indicate whether the applicant owns or operates any landfills or fuel tanks. 4. Any listed operations sold, acquired, or discontinued in the last five years? Explain and describe all such operations. 5. Is any machinery or equipment loaned or rented to others? Describe the types of equipment the applicant loans, rents, or leases to others. 6. Any watercraft, docks, floats owned, hired, or leased? Describe any watercraft or waterfront exposures. Indicate if the facilities are for private use or available to the public.

7. Any parking facilities owned/ rented? Describe if the facilities are for the use of employees, customers, visitors, etc. Give the area in square feet. 8. Is a fee charged for parking? If a fee is charged for parking, indicate whether the parking is available to the public or used primarily by employees. List the number of locations involved, and how many parking facilities are at each location. 9. Are any recreational facilities provided? Describe any recreational facilities provided for both employees or non-employees. This should include gymnasiums, grandstands, bleachers, parks, playgrounds, exercise rooms, or swimming pools owned or maintained by the applicant. 10. Is there a swimming pool on the premises? State size, maximum depth, and whether or not the pool is equipped with a diving board or water slide. Also note if a lifeguard is on duty when the pool is open. 11. Any sporting or social events sponsored? Describe the nature of such events and include the location and number of spectators and participants. If the applicant sponsors athletic teams, indicate whether the teams are composed of employees or others, such as Little League. 12. Any structural alterations contemplated? List any anticipated new construction for any locations included in the insurance being requested. Explain who will do the work: employees or subcontractors. Provide the payroll of employees or the cost of the work if subcontracted. 13. Any demolition exposure contemplated? Describe any demolition work contemplated by the applicant. Identify the structure and who will be performing the work. 14. Has applicant been active in or is currently active in joint ventures? List venture's name and address along with the role of the applicant. 15. Do you lease employees to or from others? List the companies involved, whether you are the lessor or lessee and attach a copy of the lease agreement. 16. Is there a labor interchange with any other business or subsidiaries? List the companies involved and outline the agreement. 17. Are daycare facilities operated or controlled? Indicate if facilities are for employees children only or open to the public. List number of children watched on a daily basis. If off premises give location of operation. 18. Have any crimes occurred or been attempted on your premises within the last three years? Describe any crimes or attempted crimes (e.g., burglaries, robberies, etc.). 19. Is there a formal, written safety and security policy in effect? If yes, provide a copy of the written safety or security policy in cases where your company requires this information. Indicate if these policies are practiced on a regular basis. Describe activities and precautions that are taken with respect to safety and security, including use of outside security firms. 20. Does the businesses' promotional literature make any representations about the safety or security of the premises? If yes, provide copes of such literature. REMARKS Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments such as Hold Harmless agreements, literature, brochures, labels, warnings or product surveys are being sent.

Commercial Insurance Application/Applicant Info 125 (4/2001)

The underwriting process for any commercial account begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Commercial Insurance Applicant Information Section. The Applicant Information Section is the foundation on which the ACORD commercial application program is built. This form contains information that is not duplicated on other ACORD commercial application forms. The Applicant Information Section is a required part of every commercial submission except Workers Compensation, and no commercial application is complete without it.

IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Phone (A/C, No, Ext), Fax No. Producer's telephone and fax numbers. Producer Producer's name, address and telephone number. In Florida and Nebraska, also include the producers state license number, and in Nebraska, add the agency state license number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Carrier Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. NAIC Code Individual company code assigned by the NAIC. Underwriter/Und. Off Use these fields to direct the application to a specific company underwriter and company office. Policies or Program Requested Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed. Policy Number Use this field to provide the policy number if a policy has already been issued. Sections Attached A checklist indicating the other ACORD application sections that are attached to complete the submission. If there are any other additional forms attached enter the form name on the blank line. The form numbers associated with the listed section names are: · Property - ACORD 140 · Glass & Sign - ACORD 144 · Accounts Receivable/Valuable Papers - ACORD 145 · Crime - ACORD 141 · Miscellaneous Crime - ACORD 151 · Transportation/Motor truck Cargo - ACORD 143 · Equipment Floater - ACORD 146 · Installation/Builders Risk - ACORD 147 · Electronic Data Processing - ACORD 148 · Commercial General Liability - ACORD 126-S or ACORD 126-N · Business Auto - ACORD 127, and ACORD 137 for the state where the · insurance will be written · Truckers/Motor Carriers - ACORD 132, and ACORD 137 for the state where · the insurance will be written · Garage - ACORD 128 · Vehicle Schedule - ACORD 129 · Boiler & Machinery - ACORD 155 · Workers Compensation - ACORD 130 · Umbrella - ACORD 131-S or ACORD 131-N Additional ACORD forms, such as state-specific forms, may also be filled in. STATUS OF TRANSACTION Indicate which company response to this application is expected. If the risk is bound, list the date and the time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes. PACKAGE POLICY INFORMATION

Use this section to indicate common effective and expiration dates or common billing and payment plans for package policies. Proposed Eff. Date Month/day/year on which the terms and conditions of the policy will commence. Proposed Exp. Date Month/day/year on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan The plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30.) Audit The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) Full name of the applicant as it should appear on the policy. (The first named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as "et al" or "As their interests may appear" is not acceptable as the name of the insured. These phrases do not designate legal entities. Show the federal employment identification number (FEIN) or social security number, if the first named insured is an individual. Also include the phone number and internet address (if applicable.) Mailing Address (of First Named Insured) The address at which the first named Insured is to receive all correspondence regarding the insurance. Form of Business Organization Identify the applicant as an Individual, Partnership, Corporation,Joint Venture, Subchapter "S" Corporation, Limited Liability Corporation or Other. If other, provide a description such as Professional Association or Limited Liability Company. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.) Not For Profit Organization Check this box if the company is registered as a "Not for Profit Organization". This status affects some rating classifications. Date Business Started Provide the date the applicant began in business. This is important because it helps the underwriter determine the expertise and business success of the applicant. Inspection Contact-Phone Name and telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. Accounting Records Contact-Phone Name and telephone number of the person to contact to arrange for review of the accounting records. This should be an individual under the insured's employment or their accountant, not the insurance agent's name and number. PREMISES INFORMATION Loc # Location number for this premesis. Bld # Building number for this location. Used when more than one building exists at an individual location. Street, City, County, State, Zip Code

For each location number, enter the complete physical address (not P.O. Box) including both county and ZIP Code for each location. If there are more than three locations, attach a separate list. Address should include: Street number, if any · Pre-direction, if any (e.g., 150 N Central Ave) · Street name, if any · Street type (e.g., st, rd, ave) · Post-direction, if any (e.g., 150 Central Ave N) · City · County · State · ZIP code If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal description if required by mortgage holders. City Limits For rating purposes indicate if this location is situated within the city limits. Interest Indicate the applicant's interest in each location. Yr Built Year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed. Part Occupied Identify the portion of the premises or building occupied by the applicant, such as "entire", "first floor" or "800 sq. ft. on the 10th floor." NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS This section is designed to inform the underwriter of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location (e.g., location #1 is the general offices, location #2 is the warehouse). The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as"Metal Goods Mfg. N.O.C." If the applicant is a manufacturer, describe the: · Raw materials used · Processes or work performed · Products manufactured, who uses them and how they are used If the applicant is a contractor, describe the: · Type of contractor · Work performed · Specialized equipment used · Nature of sub-contracts If the applicant is a merchant, describe the: · Type of operation, wholesale or retail (if both, give the percentage of each) · Merchandise sold, indicate if domestic or foreign manufacture · Services provided, whether or not the applicant delivers If the applicant is a service organization, describe the: · Type of service performed · Location where services are performed · Applicant's clients (e.g., general public, dentists, banks) GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the Remarks section for "Yes" responses. 1a. Is the applicant a subsidiary of another entity? If the applicant is a subsidiary of another organization, identify the parent company and describe the relationship including

the percentage owned by the parent. 1b. Does the applicant have any subsidiaries? If the applicant has any subsidiaries, provide a list and describe each relationship and the percentage owned by the applicant. 2. Is a formal safety program in operation? Some larger applicants may have formal safety programs. If this applicant does, be sure to provide an explanation of the program activities. This could have a positive impact on the underwriter's acceptance and pricing decisions. 3. Any exposure to flammables, explosives, chemicals? Provide a description of the exposure, identify the substances involved, explain any hazardous processes, and describe any precautions taken to reduce or control the hazard. If hazardous waste is generated, describe it and explain how it is disposed of. 4. Any catastrophe exposure? Describe any known exposures of this nature such as: "located on an earthquake fault," "located in a flood plain," or "next to a rocket fuel factory." 5. Any other insurance with this company or being submitted? Indicate if other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. 6. Any policy or coverage declined, cancelled or non-renewed during the prior 3 years? Provide an explanation of how this situation occurred. 7.Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Provide an explanation if any of the above exposures occurred. 8.During the last five years (ten in RI,) has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. 9.Any uncorrected Fire Code Violations? Describe any violations of applicable building codes that have not been corrected. 10. Any bankruptcies, tax or credit liens against the applicant in the past five years? If yes, Describe in detail. REMARKS/PROCESSING INSTRUCTIONS Use this space to provide detailed answers to the General Information underwriting questions outlined above. This space should also be used to provide additional information as required from other sections of the application. If additional space is needed attach a separate list. SIGNATURE SECTION Applicant's Signature Upon completion of the full commercial lines application series, the insured should review the applications and sign this form in the available space. Producer's Signature Upon completion of the full commercial lines application series, the producer should review the applications and sign this form in the available space. PRIOR CARRIER INFORMATION Space is provided to enter up to five years of information for each line of business. This information, along with the loss history below, is required to experience rate the risk. The completeness and accuracy of this information can affect the underwriter's pricing decisions. COMMON TO ALL LINES Carrier Name of the insurance company that wrote the policy. Policy Number Reference identification assigned by the insurance company to identify the policy.

Eff.- Exp. Date Show the effective and expiration date of the policy. Modification Factor The reciprocal of the percentage by which the premium shown differs from the manual. Example: if the General Liability insurance manual premium is $1,000, but the actual premium charged was reduced to $680 because of a combination of package, experience and schedule credits, the Modification Factor is .68. This factor is used by the insurance company to convert premium charged back to manual premium for application of experience rating plans. Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business. COMMERCIAL GENERAL LIABILITY Policy Type Indicate whether the policy was issued on a Claims Made or Occurrence basis. Retro Date If the policy was issued on a Claims Made basis and there was a retroactive date, list the date. If there was no date enter "none". Limits List the limits as they appeared on the policy declarations page. Limits can be listed following either the ISO simplified Policy Format or the non-simplified policy format. AUTOMOBILE LIABILITY Policy Type List the policy type that the previous policy was issued on. (e.g., Business Automobile, Truckers policy.) Limits List the limits as they appear on the policy declarations page. PROPERTY Policy Type The coverage form that the previous policy was issued on. (e.g., Special excluding Theft.) Bldg./Pers Prop Amount Indicate if the amount listed is the Building Limit or the Personal Property Limit. OTHER Complete this section for policy history on other lines of business. LOSS HISTORY Whenever possible, attach a copy of the previous carrier's loss run for each line of business. Loss reports should cover the previous five years of loss history, except in Kansas and New York, which limit the recording of loss history to three years. If loss reports are attached check the "See Attached Loss Summary" box instead of completing this section. Check Here if None Check this box if there are no known losses and no occurrences that may lead to losses over the past five years for all lines of business being submitted. See Attached Loss Summary Check this box if a loss summary report is being sent with the application. Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim. Line Line of business involved in the loss (e.g., Automobile Liability, Property, General Liability). Type/Description of Occurrence or Claim A brief description of the loss.

Date of Claim The date on which the loss or occurrence occurred. Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date. Amount Reserved If the claim is still open, list the reserve amount the previous carrier is holding open for this claim. Claim Status Indicate if this claim is open or closed. REMARKS Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures of this risk.

Commercial Policy Change Request 175 (8/2001)

This chapter provides basic instructions needed to complete the Commercial Policy Change Request (ACORD 175). Information in this chapter will refer the user to the application section chapter where the full policy sections are discussed. Additional information will be explained as necessary. IDENTIFICATION SECTION Complete this section for all change requests. Date Month/day/year on which the form is completed. Producer Producer's name, address, telephone and fax number. Code Identification code assigned to your agency or brokerage firm by the insurer receiving this form. Subcode If your agency uses sub-code identification system with the insurer, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Insured's Name First named insured as listed on the current declarations page. If this name is to be changed, list the new name in the Remarks section. Insured's Mailing Address If Changed Mailing address only if it has changed. Policy Type Policy types or lines of business within a package policy that are being changed on this request. Only one policy, as controlled by a policy number, should be entered per change request. Company Name of the applicable insurance company, and the NAIC code number of the company that issued the policy being changed. Use the "Attention" space to identify a particular underwriter, if necessary. Policy Number Policy number created by the company exactly as it appears on the policy declarations page. Effective Date of Change Date that the requested change is to commence. Only one effective date of change should be made per change request.

Policy Inception Date Effective date of the policy as listed on the policy declarations page. Policy Expiration Date Expiration date of the policy as listed on the policy declarations page. For each section below you may Add, Change or Delete data. Only one form of adjustment should be made per section. (If you check both Add and Delete, the company will not know which data is being added and which should be deleted.) Most sections have at least two iterations to handle the addition and deletion of an item such as a vehicle. PREMISES INFORMATION SECTION Refer to the chapter on the ACORD 125 for unique data element descriptions. NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Refer to the chapter on the ACORD 125 for unique data element descriptions. AUTO-VEHICLE DESCRIPTION/LIMITS If an addition or change is being made to the policy level limits, check the "Policy Limit(s) Changed" box. Also check the appropriate box for Add, Change or Delete. Limits should be adjusted in the last line of the section. To delete a limit, write "delete" in the appropriate limit box. To delete a vehicle, check the delete box and only enter the data for the Vehicle Year, Make, Model, Body Type and Vin/Serial Number. Refer to the applicable state manual for no fault/personal injury protection coverages. Each state where these coverages are available has unique mandatory coverage and unique coverage options. Use the Remarks section to describe coverage to be provided. Refer to the guidelines for ACORD 129 for other unique data element descriptions. DRIVER INFORMATION Refer to the chapter on the ACORD 127 for unique data element descriptions. WORKERS' COMPENSATION RATING INFORMATION For each classification, indicate if it is an Add (new class), Change (new premium basis) or Delete (class is to be removed). All data elements should be completed for each type of change. Refer to the chapter on ACORD 130 for unique data element descriptions. PROPERTY/INLAND MARINE - PREMISES INFORMATION Refer to the chapter on the ACORD 140 for unique data element descriptions. INLAND MARINE- SCHEDULED EQUIPMENT Refer to the chapter on the ACORD 146 for unique data element descriptions. GENERAL LIABILITY - LIMITS Use section to indicate general liability limits changes. New limits cannot be added or deleted on this form, only changed. GENERAL LIABILITY - SCHEDULE OF HAZARDS For each classification, indicate if it is an Add (new class), Change (new premium basis) or Delete (class is to be removed). All data elements should be completed for each type of change. Refer to the chapter on ACORD 126-S for unique data element descriptions. UMBRELLA CHANGES Use this section to describe changes in limits, retained limit, or other changes such as an increase or decrease in coverage provided. Describe these changes in the space provided, or use the Remarks section. ADDITIONAL INTEREST This section should be used to collect information on any additional interest or receiver of Certificates of Insurance.

Interest Check all appropriate boxes that apply to the additional interest. If other than the listed options, check the last box and list the interest type after it. Name and Address List the additional Interest's name and mailing address. Interest in Item Use section to designate exactly what the additional interest has an interest in. If the additional interest has an interest in multiple items, such as a lienholder on multiple vehicles, list all numbers associated with the additional interest. Examples: · Location 2, Building 3, Item 7 (As per schedule) · Vehicle # 2 & 3 Certificate Required If a Certificate of Insurance is required, check this box. Reference Number List any reference number such as a loan number that may help tie the additional interest to item. ADDITIONAL CHANGES/REMARKS List any additional change information required to correctly underwrite and rate the request. PRODUCER'S SIGNATURE / INSURED'S SIGNATURE Space is provided for signatures of the producer and/or the insured. Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are made that are considered significant to the company. Refer to your company rules. Many companies, or state laws, require the insured's signature when auto, liability, no fault, or uninsured motorists coverage is changed or deleted. Refer to your company or state rules.

Crime Section 141 (10/98)

This chapter provides instructions for completing the ACORD Crime Section (ACORD 141). The form addresses the basic underwriting and rating needs for Plan 1 forms A through H and Q as defined in the ISO Manual or the Surety Manual. Specific information on this plan and its sections can be found in these manuals. Additional information on Plan 1 forms I and J can be found in the Miscellaneous Crime Section, ACORD 151. Use this form in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Much of the information for this section should match the data found within the Applicant Information Section of ACORD 125, however, it is still important to complete this section. Since many companies separate applications by line of business for rating purposes, not completing this part of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Phone (A/C, No, Ext) Producer's telephone number. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID

Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on ACORD 125. Effective Date Effective date on which the terms and conditions of the policy will commence. Expiration Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan that will pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code: A S Q M O annual semi-annual quarterly monthly other

PLAN 1 This section is used to collect the coverage limits for Plan 1, forms A through H and Q. A- Employee Dishonesty If the risk is on a blanket or scheduled basis, enter the form limit and deductible. Blanket Form covers money, securities and property other than money and securities at all premises of the insured against the cause of loss in the title above. If Blanket coverage applies, complete the Employee Classification section. Schedule Form covers money, securities and property other than money and securities for the employees or employee positions shown in the schedule of this form against the cause of loss in the title above. If Schedule coverage applies, complete the reverse side of the Miscellaneous Crime Section application (ACORD 151). ERISA If ERISA Employee Dishonesty applies, check the box and show the total asset value. B- Forgery or Alteration Form covers instruments such as checks, drafts and promissory notes that are made or drawn by the insured or an agent of the insured against the causes of loss in the above title. Enter the form limit and deductible. C -Theft, Disappearance and Destruction Form covers money and securities against the causes of loss in the title. Each of its two sections has a separate limit of insurance. The limit under Section 1 applies to all premises of the insured. The limit under Section 2 applies to all messengers of the insured outside the premises. Regardless whether Blanket or Schedule coverage is selected, the money and securities exposure information should be completed for all the insured's locations on the reverse side of the application. The Safe and Vault, Messenger/Protection, and Premises/Safe Protection entries should also be completed. Complete a separate ACORD 141 for each additional covered location. For Schedule coverage, use the reverse side of ACORD 151. D -Robbery and Safe Burglary Form covers property other than money and securities against the causes of loss of robbery and safe burglary. The three limits on the application should be used as follows: Limit 1 - Inside premises - robbery of custodians Limit 2 - Inside premises - safe burglary Limit 3 - Outside premises - robbery of messengers Whether Blanket or Schedule Coverage is selected, the Property, Safe/Vault, Messenger/Protection, and Premises/Safe Protection entries must be completed for each location. If the money and securities endorsements for Coverage Form D is requested, complete information must be given. Do not request the money and securities endorsement if the applicant requests Coverage Form C. Robbery and safe burglary of money and securities is part of the theft coverage provided under Coverage Form C. E -Premises Burglary Form covers property other than money and securities against burglary, and applies to all premises of the insured.

Whether blanket or schedule, the Property, General Information and Premises/Safe Protection entries must be completed for each location. If the Special Covered Causes of Loss Coverage Form has been requested for personal property, do not request Coverage Form E. F -Computer Fraud Form covers money, securities and property other than money and securities against computer fraud. It is designed to insure against property loss caused by a non-employee using the applicant's computer system. Since the coverage is similar to a loss caused by an employee using the computer system, limits should be the same as Coverage Form A. G -Extortion Form covers money, securities and property other than money and securities against extortion. It applies to one or more premises of the insured with a single limit of insurance for all premises. H- Premises Theft and Robbery Outside Form covers property other than money and securities against theft whether blanket or schedule. Each of its two sections has a separate limit of insurance. Section 1 limit (Theft) applies to all premises of the insured; Section 2 limit (Robbery Outside) applies to all messengers of the insured. Q Robbery and Safe Burglary ­ Money and Sescurities This coverage form covers money and securities against the causes of loss in the title. It has two sections. Separate limits apply to Robbery of a Custodian and Safe Burglary under section 1 and this section applies to all premises of the insured. The section 2 limit applies to all messengers of the insured. Additional Options An additional option box is provided to insert additional Plan 1 Forms. Information on Forms I and J are found on ACORD 151. COVERAGE AMENDMENTS (Endorsements) There are many endorsements available for the various crime coverage forms. Refer to the Commercial Lines Manual or Surety Manual for the pertinent rating and underwriting information needed for each endorsement. ERISA EMPLOYEE DISHONESTY- ADDITIONAL INFORMATION (Coverage Forms A & B) Show the name of each plan, principal address, number of trustees or employees handling the plan assets, and the number of plan participants. If more than on eplan, provide the necessary information for each plan separately. CLASSIFICATION OF EMPLOYEES/LOCATIONS (Coverage Forms A & B) Complete when requesting Plan 1 Coverage forms A or B. Employee Classification Number of employees by classification who handle or have custody of money or securities. Number of Officers Number of officers other than agents or partners. Total Number of Other Employees Number of all other employees not included in the employee classification count. Manufacturers, Processors, Wholesalers or Distributors: Number of Retail Locations Number of retail locations for the listed classifications. All Other Classes: Number of Locations Other Than Home or Head Offices Number of locations other than the home or head office for all other types of classifications. CONTROLS (Coverage Form A) Fundamental information to underwrite Coverage Forms A and B. Do not submit requests for these coverages without complete information in this section. Explain any Yes responses to questions 5 - 8 in the Remarks section (e.g., if the duties described in questions 5, 6 and 7 are performed by the owner or other excluded people (partners or directors), an explanation of this will avoid future correspondence. Conversely; if the individual performing these duties is to be a covered employee, attach a narrative explaining the applicant's accounting and internal control procedures to minimize an employee dishonesty loss). Questions 5, 6 and 7 address the most common areas where employee dishonesty losses have occurred. 1. Is there an audit by? Method by which the company accounts are formally audited. 2. Audit frequency? Timing of the formal audits. 3. Does audit include inventory? Indicate if formal audits go beyond looking into the company books, and include a review of all inventory. 4. Audit report is rendered to Indicate who receives and reviews the final copy of the audit. 5. Are bank accounts reconciled by someone not authorized to deposit or withdraw?

Indicate who reconciles the accounts and how are they reconciled. 6. Is countersignature of checks required? If not, who signs? Indicate who has check-signing authority. 7. Will securities be subject to joint control of two or more responsible employees? Indicate who has control of the company securities. 8. Are all officers and employees required to take annual vacations of at least five consecutive business days? Indicate the procedures taken when book-keepers and executives take vacation, and who takes over. MONEY - SECURITIES (Coverage Form C or Q- Blanket Coverage, by Locations) Complete this section for Coverage Form C, or Coverage Form Q if you request the Money and Securities endorsement. For each category (Inside, Messenger #1, Messenger #2) carefully separate the exposure limits. Each type of exposure is rated differently. They are: Money Checks for deposit Checks for accounts payable Payroll Checks Money Overnight Securities (in bank/safe deposit) Securities, including charge account receipts from national charge accounts, will carry a rate 30 percent less than the money rate. If the applicant makes nightly deposits which reduce the overnight exposure, a reduced limit for Coverage Form C while the premises is/are closed may be requested. There is a premium credit for that reduction. If securities are in a safe deposit box, consider offering Coverage Form I (Lessees of Safe Deposit Boxes) to insure that exposure. PROPERTY (Coverage Forms D, E and H) Specify the property to be insured. Along with the property description, list the maximum value of the property. There are sublimits in these coverage forms for significantly valuable items, like jewelry made of precious metals. In such cases, the applicant is a candidate for the appropriate form of Inland Marine insurance designed for those exposures. GENERAL INFORMATION (All Coverage Forms Except A & B) This section provides basic underwriting information for Coverage Forms C, D, E, F, G and H. The gross sales information is necessary for rating Coverage Forms F and G. Business Hours Hours and days per week that the business is open for normal operations (e.g., 9:00 AM to 5:00 PM, Monday through Saturday). Avg. No. Employees on Duty Average number of employees on duty during business hours. Checks Stamped for Deposit Only Yes or No. Frequency of Deposits Frequency that deposits are made to the bank (e.g., daily, twice a week). Night Depository Used Yes or No. Annual Gross Sales or Receipts Indicate dollar amount for the last fiscal year. Double Cylinder Door Locks Indicate if the premises is protected by this type of lock. Other Information Supplemental information such as police patrol, central shopping center guard information, proprietary closed circuit television, etc. SAFE/VAULT (Coverage Forms C, D & Q) This section provides underwriting and rating information for Coverage Forms C, D and Q. If you cannot classify the type of safe, enter the exact information on the label of the safe in the Remarks area. Manufacturer Manufacturer's name of the safe or vault. Label Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe Manufacturers National Association (SMNA).

Class Construction classification representing the extent of burglary protection for this safe or vault. Use the classification from the Burglary label and not the Fire label located on the safe or vault. For industry definitions of the classifications, refer to the Commercial Lines Manual. Door Type Indicate if the door is round or square. Combination Locks Identify the presence of combination locks as well as their placement on the safe/vault. Place an "X" in all boxes that apply. Door Thickness Measurement in inches. Wall Thickness Measurement in inches. MESSENGER PROTECTION (Coverage Forms C,D & Q) This section is required for Coverage Forms C, D, and Q. Mess'gr # Messenger number to which this information applies. # of Guards Per Messenger Number of guards assigned to work with each messenger. Private Conveyance Used? Indicate if the messenger uses a car or truck provided for his/her exclusive use during the entire trip. Safety Satchel Used? Indicate if the insured's property is carried in an Underwriters Laboratories-approved safety satchel (e.g., a key-locked bank depository bag or case with handcuffs). PREMISES/SAFE PROTECTION (Coverage Forms C, D, E and H) Complete this section to describe the location's security systems. Alarm Type Style of alarm(s) protecting this premises and any safe or vault. Available options are: Hold-Up - A manual or semiautomatic control which can transmit an alarm in the event of a hold-up Premises - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The Premises Extent must be completed for Premises Alarms Safe/Vault - System that protects the safe or vault and is connected to an outside central station, gong or siren. The Extent of Protection for Safe/Vault must be completed for all safes/vaults Alarm Description Any applicable features of the alarm. Local Gong - A bell located outside the premises Central Station - A private security service which monitors the alarm system and may dispatch security officers in response to an alarm Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to police headquarters rather than to a private control station With Keys - Indicate if security service or police have keys to respond to alarms Grade Grade or class A, B, C, etc. This indicates the time required to respond to a signal from the alarm system. Please refer to manual. Extent of Protection for Safe/Vault Extent of the alarm protection for the safe or vault. Partial - Alarm covers around door only Complete - Alarm covers sides, top walls, floor and ceiling Extent of Protection for Premises Extent of the premises alarm as defined in the ISO Classification and Rating Manual. Alarm Installed & Serviced By Name of the company installing and servicing the alarm system. Alarm companies often install, maintain and service the

system, as well as to provide central station facilities. # Guards Number of guards within the premises or at its door during regular business hours. # Watchpersons Number of watchpersons on the premises during non-office hours. Watchpersons Type of watchperson reporting. Rpt/Cent. St - Report to a central station on an hourly basis Clock Hrly - Register hourly with an approved watchperson's clock (Detex Time Clock, etc.) Don't Signal - Do not do any type of reporting or registering Certificate Number Alarms which are approved by the Underwriters Laboratories (UL) are identified by a certificate. Record the certificate number. (Note: UL certification can apply to the entire system or to individual parts.) Expiration Date UL certificate expiration date. Accessible Openings & Protection Provide information regarding access to the premises. Indicate number of doors and if they are protected. Indicate what type of locks are used, and if there is a gate or bars. Other Protection Other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm). Indicate if the building has skylights and if windows are visible from the street. AUDIT PROCEDURES- SAA COMMERCIAL CRIME POLICY Complete when requesting commercial crime coverage following SAA procedures. INTERNAL CONTROLS OTHER THAN AUDIT PROCEDURES Also complete this section when requesting commercial crime coverage following SAA procedures. REMARKS Provide any additional information required for underwriting or rating. Show what corrective measures have been taken by the applicant to prevent future losses, or to provide additional safe information.

Dwelling Fire Application 84 (4/2001)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Dwelling Fire Application. The generic section of personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS. APPLICANT INFORMATION Previous Address Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address. Location of Property if Diff From Above Enter the physical address of the property to be insured only if it is different from the address listed above. Applicant's/Co-applicant's Occupation Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of business if selfemployed. Applicant's/Co-Applicant's Employer Name and Address Name and address of the organization that employs the applicant(s) named in the identification section. Yrs in Curr. Occ.

Number of years in current occupation or business. Yrs w/Curr. Empl. Number of years with present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section. Yrs w/Prior Empl. Number of years with the prior employer. Mar Stat Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Birth date of each named applicant (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44.) Social Security # Social security number for each named applicant. Questions Relating to Knowledge of Applicant and Date Property Was Inspected Indicate how long the applicant is known to the agent, and when the property was last inspected by the agent. COVERAGES/LIMITS OF LIABILITY/ ENDORSEMENTS Enter the anticipated dollar limit amounts for each applicable coverage. List any optional endorsement(s), corresponding limit(s) and any endorsement information that is to be included in this policy. Coverage Form Show the policy form, form number or company form designation for the type of policy/coverage desired. Deductibles Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) Premium Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit. Payment Plan Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment. RATING/UNDERWRITING Construction Type Check the primary type of building material used to construct the dwelling Yr Built Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alterations in the Remarks section. Also complete the Renovation Update section. # Rooms Total number of rooms in a residence, including full and half rooms (bath). Sq Foot Dwelling's total square feet of living area. # Apts Complete only for Tenant or Condominium policies. Enter the number of apartments (residences) in the building. Market Value Estimated total dollar amount for which the dwelling could be sold under current market conditions.

Replacement Cost Estimated total dollar amount required to rebuild the dwelling without depreciation. Structure Type Indicate the residence type. The full meaning of each abbreviation is: DWELLING . . . . . . . . . . . . . . . . . . Dwelling, intended to be a free standing, up to four family building APART . . . . . . . . . . . . . . . . . . . . . . Apartment CONDO . . . . . . . . . . . . . . . . . . . . . Condominium CO-OP . . . . . . . . . . . . . . . . . . . . . . Cooperative Usage Type Applicant's use for the dwelling. COC represents "course of construction." # Families Number of separate family units in the dwelling. # Hsehold Res Number of residents in the household. Purchase Date/Price Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format. # Units in Fire Div Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of fire divisions in the structure and the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved fire walls. Terr Code Location of the dwelling based on individual state bureau or company manual pages. Fire Prem Group The applicable premium group based upon the dwelling's location, construction and fire protection code. Some companies require this data; others generate it. Protect Class Dwelling's four character fire protection class found in individual state manuals. Distance to Hydrant Distance (in ft.) from the nearest hydrant that supports the protection class used. Distance to Fire Station Distance in miles from the nearest fire station that supports the protection class used. Fire/EC Rate Complete if residence is specifically rated. Refer to company rate manual. Fire District/Code Number Dwelling's fire district name and corresponding five character code number which can be found in the individual state manual pages. Protection Device Type For alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. Heat Type Indicate the primary and secondary types of heating devices for the residence. If no heat, check the box. If fuel storage tanks are located on the premises, describe the type and indicate the location. Use the Remarks section, if necessary. Possible types include: · · · · · · · Electric - Permanent/Portable Natural Gas Liquid Propane - Permanent/Portable Oil - Permanent/Portable Kerosene - Permanent/Portable Solar Coal - Professionally/Non-Professionally Installed

· · ·

Wood Other - Explain the heating system in Remarks section Central heating

Oil Storage Tank Location If the fuel type is oil, provide the location of the fuel oil storage tank. Examples: · Indoors completely above ground on a masonry floor · Indoors completely above ground not on a masonry floor · Outdoors and completely above ground · All other (including underground) Also show the distance from the dwelling, if the storage tank is outdoors. Renovation Type If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year. Dwelling Location Location of the dwelling within the guidelines listed. Occupied By Check the appropriate box. Deadbolt If all entry (exterior) doors are fitted with deadbolt locks, check the box Smoke Detector If the dwelling is equipped with smoke detector(s), check the box. Fire Extinguisher If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space. Visible to Neighbors If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box. Housekeeping Condition Enter an evaluation of the interior upkeep of the dwelling. Sprinkler If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. If there is no sprinkler system, leave this field blank. Swimming Pool If a swimming pool is on the residence property, check the appropriate boxes to indicate whether the pool is above ground, in ground, has a diving board or approved fence. Storm Shutters Check the applicable box. Hurr Res Glass Check the applicable box to indicate if hurricane resistant glass is installed in the structure. Bldg Code Grade Enter the ISO Building Code Grade, if applicable. Tax Code Enter the city, county or state tax code if required. Class Rated Rate the risks of similar hazard, i.e., dwellings. When using this rating method, signify by checking this box. Specific Rated Rate applying to an individual piece of property. When not using the class rating method, check this box and provide the Fire/EC Rate in the Remarks section when applicable. Occupied Daily? Check the appropriate box.

# Weeks Rented Number of weeks the dwelling is rented by the insured to others.If any apartment is rented on less than an annual basis, describe the terms. Wind Class Check the applicable wind class. Roof Type Enter the material used to construct the roof. Examples: · Composition (fiberglass, asphalt, etc.) · Metal · Poured · Slate · Tile · Wood Shake/Shingle · Other , If used, explain in Remarks Foundation Indicate which type of foundation is applicable. If Replacement Cost applies, check the appropriate box to indicate if any ACORD replacement cost worksheets apply (i. e., ACORD 40, 41, or 42.) Also provide the square footage for any basement, garage and breezeway. Rating Credits Check the appropriate boxes if any rating credit (s) apply. EC PREM GROUP/PERS LIAB TERR CODE Use these fields if the company uses Extended Coverage premium groups or personal liability territory codes. Fireplaces Check the appropriate box(es) to describe the fireplace(s).

GENERAL INFORMATION QUESTIONS Use the Remarks section to provide additional information for any questions answered with a "Yes" response. (Except questions 15, 16 and 17.) 1. Any farming or other business conducted on premises? Describe the business, where the business is conducted on the premises, and if applicable, whether corporal punishment coverage is to be provided. 2. Any residence employees? Describe the number and type of full and part time employees. 3. Any flooding, brush, forest fire hazard, landslide, etc.? Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph. 4. Any other residence owned, occupied or rented? Use the Remarks section to describe the occupancy or use of the other residence. If no liability coverage is requested for this residence and this policy will provide liability coverage, detail where the coverage for the other residence is provided. 5. Any other insurance with this company? Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. 6. Has insurance been transferred within agency? Indicate why this insurance has been moved from the last company. 7. Any coverage declined, cancelled, or non-renewed? Explain the circumstances surrounding this situation. Indicate the reason for the cancellation, etc. This question cannot be asked in Missouri. 8. Has applicant had a foreclosure, repossession or bankruptcy during the past five years? Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing during the specified time period.

9. Are there any animals or exotice pets kept on the premises? Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also, give any history of biting or causing injury to others or to other animals. 10. Is property located within two miles of tidal water? Use the Remarks section to describe the coastal hazard, if applicable. 11. Is property situated on more than five acres? Use the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose. 12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description. 13. Is Building retrofitted for earthquake? Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest "earthquake resistant" technology and building codes. 14. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. 15-17. Renters and Condos Only Indicate if: 15. There is a manager on the premises. 16. A security attendant. 17. The building entrance is locked. 18. Any uncorrected code violations? Describe any violations of applicable building codes that have not been corrected. 19. Is building undergoing renovation or reconstruction? Describe the type and scope of renovation or reconstruction of any part of the building. 20. Is the house for sale? Provide the length of time the house has been for sale, and the expected sale date if known. 21. Is property within 300 ft. of a commercial or non-residential property? Describe the occupancy of any commercial or non-residential property. 22. Is there a trampoline on the premises? Describe the device. 23. Was the structure originally built for other than a private residence and then converted? Describe what the structure was originally built for. 24. Any lead paint hazard? Describe the location and extent of the hazard. 25. If a fuel oil tank is on premises, has other insurance been obtained for the tank? Give the First Party to the insurance and the applicable limit, and the Third Party and the applicable limit. LOSS HISTORY This section shows the losses this applicant has had in the past. List losses for the last three years unless the company requires a different period of time. OTHER STRUCTURES Describe the other structure(s) and its coverage limit to be included under Coverage B - Other Structures. PRIOR COVERAGE Prior Carrier

Provide the prior insurance company's name. Prior Policy Number /Expiration Date List the complete policy number including prefix and suffix, and the policy's expiration date. Risk New to Agency Indicate whether this is the first time this agency has written this line of business for this applicant. ADDITIONAL INTEREST Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder (i.e., bank in which the mortgage is held), or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.

Electric Data Processing 148 (2/2000)

This chapter provides basic instructions for completing the ACORD Electronic Data Processing Section (ACORD 148). The form has been designed to handle the basic underwriting and rating needs for issuing an EDP policy. Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Most information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. however, it is still important to complete the section. Many companies, for rating purposes, separate the applications by line of business. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Effective date on which the terms and conditions of the policy will commence. Expiration Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). PREMISES INFORMATION Use this section to collect the coverage information applicable to the entire policy or to an individual location. If coverages differ by location, multiple applications must be completed. Location Number Premises location number as found in the premises information section on the ACORD 125. If the coverage limits are blanketed, leave this section blank. Building Number If multiple buildings exist for the above location number, enter the number assigned to this building. For each subject of insurance, use the following fields: Limit of Insurance Insurance amount that this subject of insurance is to be written at. If a coinsurance percentage applies to this coverage, this is the coinsurance limit (e.g., $1 million of coverage written at 80 percent coinsurance is listed as $80,000). Valuation Type Indicate which type of value was used in determining the limit of insurance. ACV = Actual Cash Value

RC = Replacement Cost Other = List type in the Remarks section. Coin % Coinsurance percentage used at time of loss. Deductible Requested deductible amount for this subject of insurance. Forms and Conditions to Apply All form numbers and special conditions applicable to this subject of insurance. Subjects of Insurance Indicate the limits, valuation types, coinsurance percentage and deductibles by the desired subjects of insurance. Equipment (Hardware) Owned If covering owned equipment (not leased), list the insurance limit, valuation type, coinsurance percentage and forms and conditions. This is a separate limit from the leased equipment. Equipment (Hardware) Leased List the Leased equipment limit separately from the Owned equipment limit. Attach a copy of the lessors contract for all leased equipment and also complete the Additional Insured section for the lessors. Equipment (Hardware) in Transit For coverage while equipment is in transit, complete this line. Media/Data (Software) Limit in terms of the reproduction cost of the software programs, the insured's data and the disks and tapes on which the data is stored. Media/Data (Software) in Transit For coverage while the media/data is in transit, complete this line. Extra Expense For the Restoration Period, enter the total number of days expected to be fully operational after a total loss. Business Interruption Insurance Limit, the limit per day and number of days for coverage. For deductibles, enter the dollar amount for the deductible and the number of hours to be applied before the deductible goes into effect (waiting period hours). Mechanical Breakdown Check the appropriate box to indicate whether this coverage is applicable. Protection and Control System List coverage information if separate limits apply to the security systems for the EDP equipment. Other Complete for any additional EDP coverage. Flood Coverage If flood applies, check "Yes" and fill in the flood zone. Check the box that pertains to floor level where the better percentage of the EDP equipment is located. If flood coverage does not apply, check "No." Earthquake Coverage If earthquake coverage applies, check "Yes" and fill in the earthquake zone. If earthquake coverage does not apply, check "No." RATING INFORMATION Complete the following information as it applies to the building where the EDP equipment is located. Building Construction Type Construction for the building. Common construction classifications are: Frame Joisted Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive Fire Resistive Prot Class Fire rating protection class for this location. # of stories for this building, not including any basement.

Year Built Year in which the building was first constructed. SCHEDULE OF EQUIPMENT Individually schedule hardware. Loc. # Location number (as found on the ACORD 125-S) for this piece of equipment. Bldg # Corresponding building number for where this piece of equipment is located. Item # A unique number assigned to this piece of hardware by the insured. Numbers are usually sequential, starting with one (1). Manufacturer Manufacturer's name. Model Model name or number. Serial # Serial Number assigned to this piece of equipment by the manufacturer. Leased or Owned Ownership status of this piece of equipment as "Leased" or "Owned." Current Full 100% Value The amount it would currently cost to replace this piece of equipment with the exact same model. Due to the nature of computer equipment, this value may be substantially less than the applicant's original purchase price. Amount of Insur. (Coinsurance %) Amount the piece of equipment is to be insured for at its coinsurance level and requested valuation type. Totals Total of the current full value column and the amount of insurance column. REMARKS Provide any additional information required for underwriting or rating. GENERAL INFORMATION Provide additional information for any questions answered "Yes". The following overview lists information that should be added to the remarks section for "Yes" responses. 1. If a major or total loss occurs, could you return to operation within one week? Outline steps you have taken to prepare to return to work within one week. 2. Do you have an arrangement for the use of other equipment? Outline with whom and from where you have arranged to obtain equipment. Indicate whether or not any emergency arrangement has been successfully tested. 3. Is your equipment manufacturer in a position to replace your equipment promptly? Outline any arrangements you have made with the manufacturer to replace equipment in case of a loss. 4. Is your equipment under manufacturer's warranty? List expiration dates of the manufacturer's warranty. 5. Do you have a service or maintenance contract with a manufacturer or other service contractor? List the establishment with which you have the contract, contract numbers and expiration dates. 6. Is the equipment shipped by common carrier? List the common carrier's name that is contracted to handle your shipping needs. 7. Is the equipment shipped by company vehicle? List the shipping vehicle. 8. Is the media/data shipped by common carrier? List the common carrier's name. 9. Is the media/data shipped by company vehicle? List the shipping vehicle. 10. Does the premises have a burglar alarm? Describe the alarm system. 11. Does the applicant have any of the following devices to protect the hardware from power line problems?

Check each type of device used. COMPUTER ROOM INFORMATION 1. Is the data processing equipment located in a specifically designated room? Briefly describe the computer room, security controls and environment controls. 2. Is access to the room restricted? Describe security controls that restrict non-authorized personnel. 3. Is the equipment controlled by a master shutdown switch? Describe where the switch is located. 4. Is there a separate air-conditioning system designed to specifically protect the EDP equipment? List the make and model of the air-conditioner and if it operates on an uninterruptible power supply. 5. Computer room protection systems Indicate all fire protection systems used in the computer room. 6. Floor construction type If the computer room has a raised pedestal floor, check the appropriate boxes for both the floor construction type and the type of fire protection for the space below the floor. 7. Alarm Type Indicate any applicable alarm types for each of the listed alarm systems: Temperature, Humidity, Smoke, Fire. Local - rings only on the premises Central - monitored by the police or a security service MEDIA AND DATA (SOFTWARE) INFORMATION 1. Are anti-viral safeguards in effect? Indicate what type of anti-viral safeguards are used, such as closed system or use of virus checker programs. 2. Are duplicates of software maintained? Software is the operating program(s) and program codes. If backups are kept, complete the software duplicates and Data Backup Storage section. 3. How often is data backed up? Indicate how often data is backed up by checking the appropriate box. Data is the variable information entered into the software program. SOFTWARE DUPLICATES & DATA BACKUP STORAGE Duplicate Software Indicate the location where duplicates of all software are kept. If off premises, list name and address of site below. Data Backups Indicate the location where backups of all data are kept. If off premises, list the name and address of the site below. On Premises Location Information Indicate the location where the duplicate software and data backups are stored on site. ADDITIONAL INTEREST Collect information on any additional interest and/or receiver of Certificates of Insurance. Interest Check all boxes that apply to the additional interest. If other than the listed options, check the last box and list the interest type after it. Name and Address List the additional interest's name and mailing address. Interest in Item Designate what the additional interest has an interest in (e.g., Location 2, Building 3, Item 7 [as per schedule]). If the additional interest has an interest in multiple items, such as a lienholder on multiple pieces of computer hardware, list all of the numbers associated with the additional interest. Certificate Required If a Certificate of Insurance is required, check this box. Reference # List any reference number, such as a loan number, that may successfully tie the additional interest to item. REMARKS Provide any additional information required for underwriting or rating.

Equipment Floater Section 146 (5/2000)

This chapter provides basic instructions for completing the ACORD Equipment Floater Section (ACORD 146). Although the main function of this form is to collect underwriting and rating information for contractors' equipment schedules, it may also be used for any other applicable Inland Marine coverage and schedule including those for cameras, musical instruments and physician and surgeon equipment. Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Most information for the Identification Section should match the data found within the Applicant Information Section (ACORD 125). however, it is still important to complete the section. Many companies, for rating purposes, separate the applications by line of business. Not completing this part of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code: A = annual S = semi-annual Q = quarterly M = monthly O = other. TERRITORY OF OPERATION Specify exactly where the equipment or schedule of items is normally located. For a specific location, give the address, or information such as the construction site name and address, city, county or state. TYPE OF OPERATION Describe the type of work performed by the applicant and nature of this business. This information may also appear on the Application Information Section (ACORD 125). If so, enter "see ACORD 125". COVERAGE/DEDUCTIBLE List the form of coverage desired and all appropriate deductibles in the space provided. Indicate if the Floater is to be written on a Scheduled or Blanket basis. If scheduled, list all items. Specify if All Risk or Named Perils. Enter any other options chosen such as Replacement Cost or Actual Cash Value and the desired deductible. Deductibles may be written on a "dollar amount" or "percentage" basis. Specify how the deductible is to be applied if not familiar with each company's policy (e.g., Contractors' Equipment, Commercial Articles Floater or Musical Instrument Dealers). EQUIPMENT STORAGE Collect limit information applicable to contractor's equipment. If other limits for such coverages as Commercial Article Floaters fit, enter them here. Limits that don't fit within these section headings should be listed within the Coverage and Deductible section. Months in Storage Number of months equipment is kept in storage. (If less than one month, enter one. All partial months should be rounded up). Maximum Value in Building Indicate the maximum value of the scheduled items stored inside a building.

Maximum Value Outside Indicate the maximum value of all scheduled items stored outside. Type of Security Briefly describe the kind of security employed by the applicant at each location. Specify guards, alarms, fences, dogs, etc. UNSCHEDULED EQUIPMENT It may be unnecessary to individually schedule all items owned by an applicant. This section should be used to group similar items together for unscheduled coverage. Description Describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lenses). Maximum Item Maximum value of any single item within this grouping. Amount of Insurance The total value of all of the unscheduled items. Values can be either on a Replacement Cost or Actual Cash Value basis. Coinsurance Percent Coinsurance percentage contemplated by the amount of insurance required. Most insurers require 100 percent coinsurance. ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS Collect information on any additional interest or receiver of Certificates of Insurance. Name and Address List the additional Interest's name and mailing address. Interest List the scheduled item's item number and the interest in the item. Examples: Item 15, Loss Payee Item 2, Additional Insured Item 1, Additional Insured/Lessor Certificate Required If a Certificate of Insurance is required, check this box. GENERAL INFORMATION The underwriting questions have been designed for applicants dealing in contractors' equipment. The Remarks section provides additional information for any questions answered "Yes" and for applicants not associated with contractors' equipment. The following overview lists information that should be added to the Remarks section for "Yes" responses. 1. Equipment rented, loaned to or from others with or without operators? If the applicant is involved in any sort of rental or loan agreement, explain the circumstances and the nature of the agreement, including who is carrying the insurance for the equipment. 2. Is applicant operating equipment not listed here? Indicate if applicant owns, leases, or hires equipment not to be insured by this policy. Identify equipment and nature of operations. 3. Property used underground? Indicate if any work is done underground and if equipment is left underground. Explain all circumstances of underground operations. 4. Any Work Done Afloat? Indicate if any work is done on bodies of water and if equipment is left afloat unattended for extended periods. Explain circumstances and indicate which bodies of water are involved. REMARKS Provide any additional information required for underwriting or rating. SCHEDULED EQUIPMENT Individually schedule items. % Coinsurance Indicate the percentage of coinsurance used to compute the insurance amounts provided on the equipment schedule. Most insurers require 100 percent coinsurance. # Assign an individual item number to each item scheduled. Model Year

Model year of each item scheduled, or the specific year in which the equipment was manufactured, if applicable. Description Describe the item to be insured. For each item listed, include the manufacturer, model number, make and any other important information to identify the equipment. ID#/Serial No. Item's identification or serial number or any other identifying symbol. Date Purchased Date when each piece of equipment was purchased by the applicant. New/Used Indicate if the item scheduled was purchased new or used by the applicant. Amount of Insurance Amount of insurance representing the liability limit for this particular described equipment. The limit should reflect the required coinsurance percentage and the requested basis of valuation (ACV or Replacement Cost).

Evidence of Property Insurance 27 (3/93)

The Evidence of Property Insurance (ACORD 27) provides a coverage statement for mortgagees, additional insureds and loss payees. Often, the form replaces the need to send a complete policy to banks, savings and loans and other lenders, as well as other additional insureds. The purpose of the ACORD Evidence of Property Insurance (EPI) is significantly different from the Certificate of Property Insurance (ACORD 24). Like the Certificate of Insurance, the EPI summarizes property insurance coverages currently in force on a policy. However, it differs by conveying to the holder of the form all rights that go with the policy, including notice of cancellation. These "rights" apply only to individuals identified on the policy. In creating this form, ACORD received input from the American Bankers Association, the Mortgage Bankers Association of America, the Federal Home Loan Bank Board and the Federal National Mortgage Association. Research reveals that information included on the form satisfies requirements of mortgagees and other additional insureds in most situations. Discussions with various lenders indicate that inclusion of items such as coinsurance are not important. The primary concern is that the amount of insurance is sufficient to cover the amount of the loan. Sufficient space is provided in the Coverage and Remarks sections of the form to include any additional information that may be required. Although many lenders pay the premium for certain types of policies such as Homeowners, inclusion of the premium amount is inappropriate on the EPI. This information will be communicated to the payor via an invoice. Furthermore, in the case of continuing coverage, the premium amount would be invalid after the first year. IDENTIFICATION SECTION Producer Producer's name, address and telephone number. Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company providing the policy coverages. Subcode If the agency use code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name and address of the applicable insurance company. Use the actual name of the company within the group to which the policy has been issued. Do not use group names. Insured Insured's name and address as they appear on the policy declarations page. The line within this field is a margin setting for window envelopes. Loan Number Insured's loan or account number for this additional interest. Policy Number Number exactly as it appears on the policy, including prefix and suffix symbols.

Effective Date Date on which the terms and conditions of the policy commence. Expiration Date Date on which the terms and conditions of the policy expires. Continued Until Terminated if Checked If the policy is issued on a Continuous basis, check the available box. This Replaces Prior Evidence Dated If a prior Evidence of Property Insurance was issued to this additional interest and this form replaces the old one, enter the date the old form was issued; otherwise, leave this field blank. PROPERTY INFORMATION Location/Description For buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave, Endicott - Grocery Store with Apartments, or Route 66, five miles south of intersection with I99 - Tobacco Barn). For other property items, such as a vehicle (for physical damage coverages) or inland marine equipment (for lessor information), describe the item along with any available vehicle identification number or serial number (e.g., 88 Ford Fairmont VIN FM123467A88 or 82 Case Backhoe Model H-15, Ser # G5963a57). COVERAGE INFORMATION Coverage/Perils/Forms Narrative description of the coverages provided, causes of loss (perils), and the forms attached (e.g., Homeowner - HO3 0792, or Contractors Equipment CM 00 22 10 90). Amount of Insurance Amount of insurance for the associated coverage. Deductible Deductible for the associated coverage. REMARKS Remarks Space for any additional comments or to list any special conditions that may exist upon the policy. CANCELLATION Unlike the Certificate of Insurance, the Evidence of Property Insurance gives the additional interest certain rights in accordance with the policy provisions. This includes the right to receive a written notice in case of policy termination. Number of Days Number of days before cancellation that the additional interest will be notified prior to termination of the policy (e.g., 10 days). ADDITIONAL INTEREST Name and Address Name and address of the additional interest. The line within this section is a margin setting for window envelopes. Nature of Interest Indicate the type of interest by checking the appropriate box. Available options are: Mortgagee, Additional Insured, Loss Payee. Use the optional space to enter any other type of interest. Loan # List any loan number, account number or other controlling number that the additional interest may have assigned the insureds. Authorized Representative This form should be signed by an authorized representative of the issuing company.

FL Workers Compensation Application 130-FL (8/2000)

The generic Workers Compensation Application, ACORD 130, cannot be used in Florida. The ACORD Florida Workers Compensation Application is a Commercial Lines application that is self-contained, that is, it does not require the completion of the Applicant Information Section (ACORD 125). As a result, the entire Identification section should be completed. The Florida Workers Compensation Application provides for Workers Compensation, Employer's Liability, and Voluntary Compensation coverages. The Policy Information and Rating Information sections follow the Workers Compensation rules as published by the National Council on Compensation Insurance (NCCI). Other plans may be used with this form as well. Please refer to the NCCI manual for coverage definitions. ACORD and NCCI cooperated in the

development and promulgation of the Florida Workers Compensation Forms. These forms are a result of the passing of Section 3 of CS/HB 3809 (Ch. 90-201) Laws of Florida which was signed into effect July 1, 1990. The application requirement applies to new and renewal policies. Unless the insurance company has been changed, it is unnecessary to file an application on renewals after filing them the first year. This includes policies written by out-of- state agents that have covered Florida exposure. IDENTIFICATION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Company Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. Underwriter This field is used to direct the application to a specific company underwriter by name. Applicant Name Enter the full name of the applicant as it should appear on the policy. (The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as "et al" or "as their interests may appear" is not acceptable as the name of the insured. These phrases are not legal entities. Mailing Address Address at which the First Named Insured is to receive all mail. Years in Business Number of years the applicant has been in business. This is important. It helps the underwriter determine the expertise and business success of the applicant. SIC Enter the appropriate Standard Industry Class code assigned to the type of business engaged in (if known). Form of Business Organization Place an "X" in the box to identify the applicant as an Individual, Partnership, Corporation, Subchapter "S" Corporation or Other. If Other, provide a description. Example: Professional Association. If there is more than one Named Insured, list each Named Insured along with its form of organization (e.g., The Green Thumb Co., a corporation, John Jones and Bill Smith, a partnership; or "A joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc."). If the list is too long for the space provided, attach a separate list. Federal Employer ID Number The FEIN is a number assigned by the IRS that specifically identifies the applicant. This number is required in most states before a policy can be issued. A separate FEIN may apply to each entity named as an insured. For individuals, use Social Security number. NCCI I.D. Number A nine-digit number assigned to the applicant by the National Council on Compensation Insurance (NCCI). The NCCI is a rating bureau that operates in most states and also provides interstate experience rating for risks that operate in more than one state. This identification number is required in most states before a policy can be issued. It will also help insure timely and accurate calculation of experience modifications. Other Rating Bureau I.D. Number If the applicant is subject to experience rating in an independent bureau state, that state's rating bureau may assign a separate identification number. If so, enter that number here. STATUS OF SUBMISSION Use the Quote/Issue Policy/Bound boxes to indicate whether the response to this application from the company is expected to be a quote or an issued policy. If the risk is bound, so indicate, include the date coverage began and attach a copy of the binder. This application is not a substitute for a binder. You may "X" more than one box. Example: if the underwriter indicated by telephone that the risk is acceptable and coverage can be bound, you should "X" both Bound and Issue. BILLING/AUDIT INFORMATION Billing Plan

Indicate whether the agency or the company (direct) will bill the insured or other payer for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. For the Other option, use the company's specific designation for the plan being used. Example: Bi-monthly or 40-30-30. % Down For bound policies, list the percentage of the total estimated annual premium that has been (or will be) received as a down payment. Audit Record Use the boxes provided to indicate the frequency with which audits should be undertaken for this policy. LOCATIONS List all usual work places of the applicant. Provide the physical address, not post office boxes. Place an "X" beside Yes or No to show if the applicant is a long term employee leasing company. Example: Staff Leasing. If yes, then the name of the client and the address where the employees will be located must be included, in addition to the address of the applicant. POLICY INFORMATION Proposed Eff. Date The Effective Date is the date on which the terms and conditions of the policy will commence. Proposed Exp. Date The Expiration Date is the date on which the terms and conditions of the policy will expire. The normal policy period (effective date to expiration date) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term to gain concurrence with other policies. Normal Anniversary Rating Date Normally, the rates used are those in effect on the effective date of the policy. NCCI Manual rules require the rates to apply for a period of one year. If a policy is canceled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is a temporary situation that will last until the next renewal, whereupon the new policy effective date will again determine the rates. The purpose of this rule is to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For canceled or short-termed polices, enter the original effective date. Participating/Non-Participating A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans. Retro Plan Retrospective rating plans permit the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with your company on the availability of plans. Part 1 (States) Indicate the states in which Part 1 will apply. Part 1 refers to the Workers Compensation Law and/or Occupational Disease Law in states where the applicant has operations. Part 2 - Employers Liability Enter the requested limits for Part 2 of the policy (Employers Liability Insurance). The standard limits of liability under Part 2 are: Bodily Injury By Accident: $100,000-each accident/Bodily Injury by Disease: $500,000-policy limit/Bodily Injury by Disease: $100,000-each employee. Be sure to express limits with full dollar amount (all zeros shown) on the application. Other Coverages Use this space to request optional United States Longshoremen's & Harbor Worker's (U.S.L. & H.) Coverage and Voluntary Compensation Coverages. Exposures for these optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. Dividend Plan or Safety Group Identify the specific plan or the safety group of which the applicant is a member. This field is related to the participating plan. Check with your company on the availability of plans. Additional Company and State Information If Part 3 - Other States Insurance - is to be written, states falling under Part 3 need to be listed in this section. State abbreviations should be listed preceeded by the words Part 3 - Other States Insurance - Included. Any additional company or state specific information should also be listed in this section. Deductible Made available at the written request of the employer, in the amount of $500, $1,000, $1,500, $2,000 and $2,500 per claim. See the Florida Benefits Deductible And Coinsurance Programs for more details.

Coinsurance Limit Made available at the written request of the employer. The carrier will pay 80 percent and the employer will pay 20 percent per claim of the benefits due to an employee for an injury compensable under Florida Benefits Deductible And Coinsurance Programs. RATING INFORMATION Location Number The location number for each entry which corresponds to the locations listed in the Locations section above. Class Code The Classification Code which best describes the business of the applicant. It is important to remember that it is the business of the employer, not the individual employees, that is being classified. Consult the proper rating manual to determine the code. Rating bureaus may exercise control over classification assignment. Company Use Leave this space blank. The insurer may use this space for special computer codes, to identify the applicable class description wording. Categories, Duties, Classifications A single class code may include several related descriptions of activities/operations. Therefore, it is extremely important to enter the specific classification description or, at the very least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. No. of Employees Indicate the Number of Employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. Actual Remuneration Past 12 Months Indicate the remuneration (payroll) for the previous 12 months for the appropriate class. Remember, payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help to avoid additional premium at the time of audit. Estimated Remuneration for Next Policy Period The total estimated payroll for the period between the proposed effective date and proposed expiration date. Rate Enter the manual Rate for the classification from the appropriate state manual. Estimated Annual Premium The rate is applied (multiplied) to every $100 of remuneration (payroll) and the result is the Estimated Annual Premium for this classification. Total Add the amounts for each class to obtain the Total estimated pre-modified premium. Experience Modification Enter the Experience Modification factor in this space if the applicant is subject to experience rating. Generally, the business has to have been operating for at least two years under present ownership and the premium must meet or exceed a level which is established by the state to qualify for experience rating. If more than one modification factor applies to the applicant, explain the details in the Remarks section. Attach the most recent experience rating data sheet if you have a copy. Modified Premium Enter the amount resulting from multiplying the Total estimated pre-modified premium by the Experience Modification factor. Premium Discount If a Premium Discount is applicable, enter the total dollar amount to be deducted from the modified premium. This generally applies only if the policy premium exceeds $5,000. Refer to the state manual. Expense Constant Enter the applicable charge for the state Expense Constant. This charge is no longer limited only to small accounts where it was intended to recover issuing and servicing costs. Total Estimated Annual Premium Enter the Total Estimated Annual Premium resulting from applying all modifications, discounts, and other rating criteria to the Total estimated pre-modified premium. Minimum Premium The Minimum Premiums are found on state rate sheets opposite the class code; they apply by policy. If two or more classifications with different Minimum Premiums are included on one policy, the highest usually applies. Please check the appropriate rate manual.

Deposit Premium Enter the dollar amount due the insurer at inception. Specify Additional Coverages/Endorsements Use this area to explain the applicant's exposures and payroll for any other coverage requested, including U.S.L. & H. and Voluntary Compensation. INDIVIDUALS INCLUDED/EXCLUDED Sole proprietors and a maximum of three partners or corporate officers may elect to be exempted from coverage if they are actively engaged in the construction industry. For any clarification of this subject you should contact the Bureau of Compliance, at (904) 488-2713. Those persons with exemptions and inclusions signed and approved prior to enactment of the law signed on January 25, 1991, should review their status and take appropriate actions to reject or continue coverage. Certain other positions within an organization, such as sole proprietors and partners, may not be covered by the applicable Workers Compensation Law, but they may be permitted to elect to be brought under it. Conversely, executive officers of corporations are generally considered employees, but may have the option to elect to be excluded from coverage. Refer to the NCCI or applicable state Workers Compensation manual for the details. Since the inclusion or exclusion affects coverage and premium, this section must be fully completed. Name Enter the name of the partner, executive officer or relative for purposes of indicating whether or not the individual is to be covered by the policy. Date of Birth This individual's birth date. Title/Relationship Provide either the individual's title within the organization or relationship to the organization's owners. Ownership % Indicate the percentage of ownership the individual has in the organization, if applicable. Duties Briefly identify the duties of the individual. This will help to ascertain the proper classification. Inc/Exc Indicate if the individual is to be Included or Excluded under the policies coverages. Class Code Enter the Class Code for individuals to be included based on the duties described above. Remuneration Provide the estimated annual Remuneration for individuals to be included. Minimum or maximum remunerations may be applicable based on the state law. (Be sure to enter the class code and remuneration in the Rating Information section of the application for all included individuals). PRIOR CARRIER INFORMATION/LOSS HISTORY Either this section should be completed or a loss history report should be attached covering the last five years. If a loss history report is attached, enter "See Attached Report" in the first Carrier & Policy Number section. Year Enter the Year or policy period. The most recent policy period should be listed first. Carrier & Policy Number Provide the carrier's name and policy number for the corresponding policy. Annual Premium The Annual Premium for the corresponding policy. Use the final audited premium when that is available. Mod. If the risk was subject to experience rating, enter the Experience Modification in this column for the corresponding policy. # Claims Enter the total number of Claims for the corresponding policy term. Amount Paid This is the total dollar amount actually paid for all open or closed claims. Reserve Enter the amount in Reserve for any open claims, along with the valuation date of the reserves. Estimates are acceptable; enter zero if none. NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS This section is designed to inform the underwriter of what business each applicant performs and the way it is conducted

by premises. Operations which may not be apparent in a general description of operations may be segmented by location. Example: location #1 may be the general offices while location #2 may be the warehouse. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C." If the applicant is a manufacturer, describe the: Raw materials used Processes or work performed Products manufactured, who uses them and how they are used If the applicant is a contractor describe the: Type of contractor Work performed Specialized equipment used Nature of sub-contracts If the applicant is a merchant, describe the: Type of operation, wholesale or retail (if both, give the percentage of each) Merchandise sold and indicate if of domestic or foreign manufacture Services provided Whether or not the applicant delivers If the applicant is a service organization, describe the: Type of service performed Location Applicant's clients (for example: general public, dentists, banks) EMPLOYEES List all the names of the employees on the payroll. If the company has more than four employees, an "X" must be placed in the box labeled "Check if a list of additional employee names is attached". GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. 1. Does applicant own, operate or lease aircraft/watercraft? Describe any Aircraft exposure with the exception of commercially scheduled flights. Name any employee who is a licensed pilot and explain his or her duties and the type of license held. Describe any Watercraft which is owned, leased, or operated, and explain its use. 2. Do operations involve storing, treating discharging, applying, disposing, or transporting of hazardous material? (e.g. landfill, asbestos, wastes, fuel tanks, etc.) Explain the exposure and the precautionary measures implemented to handle hazardous materials. The exposures would include: flammable, explosives, radioactivity, caustics, or fumes and their storing, disposing, or transporting, or any other material with a known occupational disease exposure. 3. Any work performed underground or above 15 feet? Provide the frequency and explain the nature of such work, and the number of people involved. 4. Any work performed on barges, vessels, docks, bridge over water? Describe any work on Barges, Vessels or Docks and indicate the location, frequency, and number of people involved. 5. Is applicant engaged in any other type of business? List all other businesses and identify the carrier for that business's workers compensation coverage. 6. Are sub-contractors used? Explain the nature and frequency of any subcontracted work. Are Certificates of Insurance required? 7. Any work sublet without certificates of ins.? Describe the nature and frequency of the work subcontracted and indicate if the classifications and remuneration for such work have been included in the Rating Information section. 8. Is a formal safety program in operation? Describe the safety program. Does it involve meetings, classes, incentives? 9. Any group transportation provided? Is a van pool program in effect? Does the employer shuttle employees to job sites? What type of conveyance is used? How many employees are transported? How often? Over what distance? Provide details. 10. Any employees under 16 or over 50 years of age? If Yes, specify the number of employees in each category and the duties they perform. 11. Any part time or seasonal employees?

How many employees? How many hours do they work? At what time of the year are they employed? What are their duties? 12. Is there any volunteer or donated labor? Explain the circumstances under which volunteer labor is used and the nature of the work. 13. Any employees with physical handicaps? Describe the nature of the work and explain the circumstances under which physically handicapped workers are employed. Indicate the number of employees and the type of handicaps. Is the applicant involved in a special community program for handicapped people? If eligible, has the employee been registered in a second injury fund? 14. Do employees travel out of state? Describe the nature of the travel and indicate the number of employees, frequency and mode of transportation. 15. Are athletic teams sponsored? Describe the nature of the athletic activities and indicate the number of employees involved (if any). Indicate whether the applicant provides an accident and health policy to cover athletic activities. This may include company, school, or community teams or leagues. Example: Little League. 16. Are physicals required after offers of employment are made? Are all employees required to undergo a physical examination after they have been made an offer for employment? Describe the extent of the physical examination and indicate which applicants are required to take them. 17. Any other insurance with this insurer? If other insurance policies of any kind are in force with this insurer, identify the coverages, policy numbers, and terms. It may also be desirable to note other submissions for this account that are under consideration. 18. Any prior coverage declined/canceled/non-renewed (last 3 yrs.)? The mere fact that such action occurred is not as important as the reason for the action. Provide all the details. 19. Are employee health plans provided? Indicate the carrier name and policy number for the health plan. 20. Is there a labor interchange with any other business/subsidiary? Indicate who the interchange is being done with and their relationship to the insured. 21. Do you lease employees to or from other employers? For leasing employees indicate who you are leasing them to. For leased employees indicate who you are leasing them from and if you have a certificate of insurance from the lessor. 22. Do any employees predominantly work at home? Indicate who works at home and what their hours of operation are. 23. What are your estimated annual revenues? This requires a dollar amount, not a yes/no response. Enter the estimated revenues (income) for the next year. Inspection Enter the name and full telephone number of the individual who should be contacted in order for the insurer to conduct a physical inspection survey. Accounting Records The insurer may need to contact the applicant for audit purposes. Please provide the name and full telephone number of the individual responsible for such records. Claims Information (Phone and Name) Provide the telephone number and name of the person the insurer is to contact regarding any potential claims inquiries. Remarks Add any additional rating information, comments or other items that will assist in the classification and rating of this risk. I understand that as the employer, . . . This section spells out the conditions required of the employer in securing Florida Workers Compensation Coverage. Applicant's Signature The applicant must sign and date the form in the presence of a Notary Public. Producer's Signature The producer's signature and date the form is signed. Notary Public Signature A Notarized signature is required for the applicant's signature only (not the producer's signature).

FL Workers Compensation/Monthly Change 175-FL (11/2001)

The ACORD Florida Workers Compensation Monthly Change Sheet is to be used on new and renewal policies. This form is to be used to request monthly changes to the Florida Workers Compensation application. The form must be used as a result of the passing of Section 3 of CS/HB 3809 (Ch. 90-201) Laws of Florida which was signed into effect July 1, 1990. The form is designed to be completed by the applicant. It must be mailed to the company writing the Florida Workers Compensation coverage on a monthly basis if a change is to be made. If there are no changes, a monthly change sheet is not mandatory. This includes policies written by out of state agents that have covered Florida exposure. It is expected that all carriers will be uniformly using this monthly change sheet at this time. Copies of the monthly change sheet shall be retained for a minimum of three years. IDENTIFICATION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Company Name of the applicable insurance company. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. Underwriter This field is used to direct the application to a specific company underwriter by name. Applicant Name Enter the full name of the applicant as it appears on the original Florida Workers Compensation Application. Policy Number Number assigned by the company for the Florida Workers Compensation policy. Policy Eff. Date The Effective Date is the date on which the terms and conditions of the policy began. Pol. Exp. Date The Expiration Date is the date on which the terms and conditions of the policy will expire. INSURANCE The address of the insurance company writing the Florida Workers Compensation policy. The company name, address and zip are entered into the white space. This form may be folded at the designated line and mailed in a window envelope. APPLICANT NAME Enter the new name of the applicant as it should appear on the policy. (The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names. Example: John and Mary Smith. Wording such as "et al" or "As their interests may appear" is not acceptable as the name of the insured. These phrases are not legal entities. MAILING ADDRESS The new address at which the First Named Insured is to receive all mail. LOCATIONS List The locations that have changed since the initial application or the last monthly change sheet. Place an "X" beside add to enter a new location, or "X" beside delete to delete a location no longer in use. Provide the physical address, not post office boxes. Place an "X" beside Yes or No to show if the applicant is a long term employee leasing company. Example: Staff Leasing. If yes, then the name of the client and the address where the employees will be

located must be included. RATING INFORMATION Place an "X" for the addition of a new location or class code at the location, "X" for the deletion of an unused location or class code, or "X" if change in class code, categories, duties, classifications, number of employees or estimated remuneration for present policy period. Street, City, State The information on this change sheet must match the information provided on the original application or location information on this form. Location Number Enter the location number for each entry which corresponds to the locations listed in the Locations section above. Class Code Enter the Classification Code which best describes the business of the applicant. It is important to remember that it is the business of the employer, not the individual employees, that is being classified. Consult the proper rating manual to determine the code. Rating bureaus may exercise control over classification assignment. Company Use Leave this space blank. The insurer may use this space for special computer codes, to identify the applicable class description wording. Categories, Duties, Classifications A single class code may include several related descriptions of activities/operations. Therefore, it is extremely important to enter the specific classification description or, at the very least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations. No. of Employees Indicate the Number of Employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. Estimated Remuneration for Present Policy Period Total estimated payroll expected as a result of this change for the period between the effective date and expiration date. INDIVIDUALS INCLUDED/EXCLUDED Add if a new partner, officer, relative; delete if partner, officer, relatives employment is terminated, or change if the partner, officer, relatives title/relationship, ownership %, duties, inc/exc, class code or remuneration has changed since the original application or previous monthly change sheet. Name Enter the name of the partner, executive officer or relative for purposes of indicating whether or not the individual is to be covered by the policy. Date of Birth This individual's birth date. Title/Relationship Provide either the individual's title within the organization or relationship to the organization's owners. Ownership % Indicate the percentage of ownership the individual has in the organization, if applicable. Duties Briefly identify the duties of the individual. This will help to ascertain the proper classification. Inc/Exc Indicate if the individual is to be Included or Excluded under the polices coverages. Class Code Enter the Class Code for individuals to be included based on the duties described above. Remuneration Provide the estimated annual Remuneration for individuals to be included. Minimum or Maximum remunerations may be applicable based on the state law. (Be sure to enter the class code and remuneration in the Rating Information section of the application for all included individuals). EMPLOYEES

Add new employee, delete employee if employment has been terminated, or change due to the name provided on the original application or previous submission of the change sheet is being changed; example due to marital status. If your company has more than six changes in employee names, an "X" must be placed in the box labeled "Check if a list of additional employee names is attached". NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Used to describe a revision in the operations and should include an explanation for the revision. This section is designed to inform the underwriter of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. Example: location #1 may be the general offices while location #2 may be the warehouse. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual; it does not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C." If the applicant is a manufacturer, describe the: · Raw materials used · Processes or work performed · Products manufactured, who uses them and how they are used · If the applicant is a contractor, describe the: · Type of contractor · Work performed · Specialized equipment used · Nature of sub-contracts If the applicant is a merchant, describe the: · Type of operation, wholesale or retail (if both, give the Percentage of each) · Merchandise sold and indicate if of domestic or foreign manufacture · Services provided · Whether or not the applicant delivers If the applicant is a service organization, describe the: · Type of service performed · Location · Applicant's clients (for example, general public, dentists, banks) Remarks Add any additional rating information, comments or other items that will assist in the classification and rating of this risk. I understand that as the employer, . . . This section spells out the conditions required of the employer in securing Florida Workers Compensation Coverage. Applicant's Signature The applicant's signature and date the form is completed. Producer's Signature The producer's signature and date the form is completed.

Garage and Dealers 138

Alabama Garage and Dealers, Coverages/Limits Section ACORD 138 AL (2/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 AL. Alaska Garage and Dealers, Coverages/Limits Section ACORD 138 AK (4/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 AK. Arizona Garage and Dealers, Coverages/Limits Section ACORD 138 AZ (3/97)

Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 AZ. Arkansas Garage and Dealers, Coverages/Limits Section ACORD 138 AR (10/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 AR. California Garage and Dealers, Coverages/Limits Section ACORD 138 CA (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 CA. Colorado Garage and Dealers, Coverages/Limits Section ACORD 138 CO (1/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 CO. Connecticut Garage and Dealers, Coverages/Limits Section ACORD 138 CT (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 CT. Delaware Garage and Dealers, Coverages/Limits Section ACORD 138 DE (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 DE. District of Columbia Garage and Dealers, Coverages/Limits Section ACORD 138 DC (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 DC. Florida Garage and Dealers, Coverages/Limits Section ACORD 138 FL (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 FL. Georgia Garage and Dealers, Coverages/Limits Section ACORD 138 GA (2/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 GA. Hawaii Garage and Dealers, Coverages/Limits Section ACORD 138 HI (2/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 HI. Idaho Garage and Dealers, Coverages/Limits Section ACORD 138 ID (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 ID. Illinois Garage and Dealers, Coverages/Limits Section ACORD 138 IL (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 IL. Indiana Garage and Dealers, Coverages/Limits Section ACORD 138 IN (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 IN.

Iowa Garage and Dealers, Coverages/Limits Section ACORD 138 IA (8/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 IA. Kansas Garage and Dealers, Coverages/Limits Section ACORD 138 KS (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 KS. Kentucky Garage and Dealers, Coverages/Limits Section ACORD 138 KY (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 KY. Louisiana Garage and Dealers, Coverages/Limits Section ACORD 138 LA (6/98) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 LA. Maine Garage and Dealers, Coverages/Limits Section ACORD 138 ME (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 ME. Maryland Garage and Dealers, Coverages/Limits Section ACORD 138 MD (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MD. Massachusetts Garage and Dealers, Coverages/Limits Section ACORD 138 MA (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MA. Michigan Garage and Dealers, Coverages/Limits Section ACORD 138 MI (4/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MI. Minnesota Garage and Dealers, Coverages/Limits Section ACORD 138 MN (1/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MN. Mississippi Garage and Dealers, Coverages/Limits Section ACORD 138 MS (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MS. Missouri Garage and Dealers, Coverages/Limits Section ACORD 138 MO (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MO. Montana Garage and Dealers, Coverages/Limits Section ACORD 138 MT (8/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 MT.

Nebraska Garage and Dealers, Coverages/Limits Section ACORD 138 NE (8/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NE. Nevada Garage and Dealers, Coverages/Limits Section ACORD 138 NV (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NE. New Hampshire Garage and Dealers, Coverages/Limits Section ACORD 138 NH (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NH. New Jersey Garage and Dealers, Coverages/Limits Section ACORD 138 NJ (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NJ. New Mexico Garage and Dealers, Coverages/Limits Section ACORD 138 NM (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NM. New York Garage and Dealers, Coverages/Limits Section ACORD 138 NY (4/98) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NY. North Carolina Garage and Dealers, Coverages/Limits Section ACORD 138 NC (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 NC. North Dakota Garage and Dealers, Coverages/Limits Section ACORD 138 ND (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 ND. Ohio Garage and Dealers, Coverages/Limits Section ACORD 138 OH (3/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 OH. Oklahoma Garage and Dealers, Coverages/Limits Section ACORD 138 OK (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 OK. Oregon Garage and Dealers, Coverages/Limits Section ACORD 138 OR (7/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 OR. Pennsylvania Garage and Dealers, Coverages/Limits Section ACORD 138 PA (9/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 PA. Rhode Island Garage and Dealers, Coverages/Limits Section ACORD 138 RI (3/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 RI. South Carolina Garage and Dealers, Coverages/Limits Section ACORD 138 SC (4/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 SC. South Dakota Garage and Dealers, Coverages/Limits Section ACORD 138 SD (2/97) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 SD. Tennessee Garage and Dealers, Coverages/Limits Section ACORD 138 TN (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 TN. Texas Garage and Dealers, Coverages/Limits Section ACORD 138 TX (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 TX. Utah Garage and Dealers, Coverages/Limits Section ACORD 138 UT (1/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 UT. Vermont Garage and Dealers, Coverages/Limits Section ACORD 138 VT (1/2001) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 VT. Virginia Garage and Dealers, Coverages/Limits Section ACORD 138 VA (10/98) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 VA. Washington Garage and Dealers, Coverages/Limits Section ACORD 138 WA (8/2000) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 WA. West Virginia Garage and Dealers, Coverages/Limits Section ACORD 138 WV (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 WV. Wisconsin Garage and Dealers, Coverages/Limits Section ACORD 138 WI (4/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 WI. Wyoming Garage and Dealers, Coverages/Limits Section ACORD 138 WY (3/96) Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for ACORD 137 WY.

Garage and Dealers Section 128 (3/2001)

This guide provides the user with basic instructions for completing the ACORD Garage & Dealers Section. This form has been designed to handle the basic underwriting needs for automobile service operations and automobile dealers. Space is provided to enter driver information for up to eight drivers. For additional drivers, ACORD 163, Driver Information Schedule, can be attached. Insurance coverage, "no fault" and uninsured/underinsured motorists coverages in particular, varies widely from state to state. In addition, there are numerous state-specific requirements that apply to Garage and Dealers applications. ACORD 128 cannot address these various unique specifications. Therefore, state specific forms, ACORD 138, have been developed to respond to these requirements. Use the ACORD 138 for your state to provide coverages/limits information, as well as the required disclosure and other data unique to the state. See the State Forms section of this Guide for more information. This form was alsodesigned to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125) and the Vehicle Schedule (ACORD 129). Please turn to the chapters on these forms for specific information on completing them. Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in most states. Refer to the State Forms section of this Guide. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Enter the Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan

Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Use this field to indicate the audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other BUSINESS/VEHICLE STORAGE INFORMATION This section is used to identify the type of insurance necessary for the applicant. Auto Service Operations or Trailer Sales Place an "X" in all applicable boxes to identify the type of operations in which the applicant is involved. Auto Dealers Indicate if the dealership is franchised, deals in one or more specific lines of cars such as Ford or GM, or if it is a non-franchised dealer. Indicate the percentage of vehicle style in relation to total inventory. Vehicle Storage Indicate where the applicant's vehicles are stored. Location Number Enter the location number as it relates to the numbers found on the ACORD 25. For each location, identify where the vehicles are stored. Building Vehicles are stored within a building. Standard Open Lot The lot is enclosed by walls or fences at least six feet in height, with openings securely locked when unattended. Non-Standard Open Lot The lot is either an open lot or an unroofed space and the building is not securely enclosed or locked when unattended. COVERAGES/LIMITS Covered Auto Symbols Garage or Dealers policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 21 through 26 provide fleet automatic coverage. Symbol 21 includes Hired and Non-Owned auto coverage. If symbol 21 is not used and Hired Auto (symbol 28) or Non-Owned Auto (symbol 29) coverage is desired, those symbols must be checked. The symbols indicate the automobiles to which each coverage applies. The symbol "triggers" the coverage. For exact policy definitions of the symbols, please refer to the company's policy declarations page. Symbol 21 - Any Auto Can only be used for Liability insurance and/or Medical Payments insurance. Its use provides coverage for any auto the insured will have contact with, including owned & non-owned & hired vehicles. It includes coverage for non-owned autos, no-fault, uninsured motorists or physical damage insurance. Damage to customers' autos is provided by using Symbol 30, Garage Keepers Insurance. Symbol 22 - All Owned Autos Provides coverage for owned autos only and includes automatic coverage for autos you newly acquire. This symbol cannot be used to provide liability coverage for dealers, but can be used to provide liability for non-dealers. It can also be used for dealers and non-dealers to provide any of the physical damage coverages or uninsured motorist's insurance. Symbol 23 - Owned Private Passenger Autos Only

Provides coverage for owned private passenger autos only and includes automatic coverage for private passenger autos you newly acquire. It can be used for dealers and non-dealers to provide uninsured motorist's insurance and physical damage coverages. It may also be used to provide medical payments insurance for non-dealers. Symbol 24 - Owned Autos Other Than Private Passenger Provides coverage for owned autos other than private passenger autos and includes automatic coverage for autos you newly acquire, other than private passenger autos. It is not limited to trucks or truck tractors, but also includes taxis, motorcycles, emergency vehicles, trailers and buses. Any vehicle which is not a private passenger auto fits within this symbol. Symbol 25 - Owned Autos Subject to No-Fault Laws Applies to owned autos where no-fault is required by law including automatic coverage for autos you newly acquire. Symbol 26 - Owned Autos Subject to Uninsured Motorist Laws Applies to owned autos where there is a compulsory uninsured motorist's law including automatic coverage for autos you newly acquire where rejection of UM is not permitted by law. Symbol 27 - Specifically Described Autos Provides coverage for scheduled autos only with no automatic coverage for autos you newly acquire. Use Vehicle Schedule, ACORD 129, to provide information on individual vehicles. Symbol 28 - Hired Autos Only Provides coverage only for autos leased, hired, rented or borrowed by the named insured. This does not include autos owned by employees or members of their families. Symbol 29 - Non-Owned Autos Used in Garage Business Provides liability coverage for autos not owned by the named insured but used in connection with the garage business. This includes autos owned by employees. Symbol 30 - Autos Left for Service/Repairs/Storage Provides coverage for customer's autos which are in the care, custody, and control of the named insured. It provides garage keepers insurance for dealers and non-dealers when autos are left for service, repair or storage. Symbol 31 - Autos On Consignment and Dealer Autos Provides physical damage coverages for autos consigned to dealer or held for sale in possession of non-dealer. Symbol 32 - Company Use This is a company specific code. It can be used to provide coverage when no other symbol applies (e.g., to provide coverage for Long Term Leased Vehicles). It will be necessary to write in this symbol if used. Coverages & Limits - Use ACORD 138 AUTO DEALERS OPERATORS The Insurance Services Office developed the Dealers Class Plan to rate liability and collision coverages. The basis for rating involves assigning rating factors and rating units for employees and non-employees. Record by location the number of persons within each category. If rating the policy, refer to the Commercial Lines Manual for additional information. DEALERS PHYSICAL DAMAGE Indicate if the autos to be covered are New or Used for each coverage and check the interest to be insured. NON-DEALERS PREMISES & OPERATIONS Payroll is the basis for rating this coverage. Enter the location number as it appears on the ACORD 125, the estimated annual remuneration and number of employees at each location. See the appropriate manual for the payroll limitations that apply. DRIVER INFORMATION

This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member who will be driving company vehicles and employees who regularly drive their own vehicles for company business. Name Enter the driver's full name. If the company requires the address, enter it as well. Sex Enter F for female, M for male. Marital Stat Enter the marital status for each driver. Examples: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Enter the driver's birth date. Yrs Exp Enter the number of years of driving experience for each driver. Year Licensed Enter the year in which the driver was first licensed. Driver's License Number/Soc. Sec. # Enter the complete driver's license number. If a license number is unavailable, enter the driver's social security number. State Lic. Enter the state in which the license was issued. Date Hire Enter the date of hire for each driver. Use Vehicle and % Enter the vehicle number that this driver primarily uses and the percentage of driving done by this driver in this vehicle. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. 1. Does applicant rent, lease or loan vehicles to others? List the frequency, who receives the vehicles and if this is part of the normal business operations. Indicate if insurance is provided. 2. Does applicant pick-up or deliver customer's cars? Indicate how many cars per day, and how the employee commutes to the location. 3. Does pick-up or delivery exceed 50 miles? Indicate the radius of this operation if it exceeds 50 miles, and how often. 4. Is tire recapping or retreading performed? List the percentage of gross sales this operation represents. Indicate if the applicant sends out for retreads, or if the applicant performs the operation. 5. Does applicant own or sponsor a car for racing? Provide a description of the car. Indicate how frequently the car is raced, who drives the car and how the car is transported. 6. Does applicant handle butane, propane or other gases? State what type of storage facilities are used, what gases are involved and if they are for sale to the general public. 7. Are any vehicles furnished for groups or organizations?

Identify the group (school, hospital, church, or civic organization) to which the vehicle is loaned. Indicate if there is a charge. 8. Does applicant perform spray painting or welding? Indicate how frequently this type of operation is performed, and if the applicant has approved booths or ventilated spray areas. Describe the type of welding or painting job handled and where in the building each job is located. 9. Does applicant drive away or haul away vehicles from factory distributing point or other dealers? Describe circumstances causing drive-aways. Indicate if this is a regular operation, how many cars are involved, and give the radius of operation. 10. Does applicant dismantle autos or have salvage operation? Describe this type of operation completely. If there is a salvage operation on premises, so indicate. 11. Does applicant use tow trucks? Indicate how many trucks are owned or used by the applicant and describe towing operations. These trucks may be listed on ACORD 129 Vehicle Schedule and attached to the Garage Section. 12. Do employees regularly use their own autos on company business? List who, what vehicle and for what operations. 13. Does applicant park customers' vehicles on public streets or off premises? Describe any type of off-premises parking of vehicles. 14. Is a charge made for parking? Indicate how much is charged, how many attendants are on duty, and the hours of operation. Indicate if employees drive vehicles or if customers self-park. 15. Any private protection systems? Describe all such systems in detail. 16. Is applicant involved in any "non-garage" operations? If a retail operation, mini-mart, liquor store, or other operation is run on the premises, list the operation and annual gross sales from this portion of the business. Indicate if there is any insurance for this operation. 17. Does applicant perform any road emergency services? Indicate if the applicant is on call for any highway or other emergencies, and if towing operations are available around the clock. 18. Any drivers with moving traffic violations? Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company's and state's requirements. ADDITIONAL INTEREST Use this section to collect information on any additional interest or receiver of Certificates of Insurance. Interest Check all appropriate boxes that apply to the additional interest. If the interest is other than the listed options, check the last box and list the interest type after it. Name and Address List the additional interest's name and mailing address. Interest in Item Use this section to indicate what the additional interest has an interest in. Examples: · For a Mortgagee, list the location and building number. · For an automobile lienholder, list the vehicle number. If the additional interest has an interest in multiple items, such as a lienholder on multiple vehicles, list all of the numbers associated with the additional interest. Certificate Holder

If a Certificate of Insurance is required, check this box. Reference Number List any reference number, such as a loan number, that may be beneficial in tying the additional interest to item. REMARKS Use this section to provide any additional information required for underwriting or rating.

General Liability Notice of Occurrence/Claim 3 (1/2002)

Use ACORD 3 to report both commercial and personal liability losses. IDENTIFICATION SECTION Date Month/day/year on which this form is completed. Producer Producer's name and address. Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Notice of Occurrence / Notice of Claim Mark the appropriate block. Notice of Occurrence applies to both occurrence policies and to the report of incidents for Claims Made policies. The Notice of Claim applies only to Claims Made policies and is used for the reporting of suits or actual claims filed against the insured. Date of Occurrence and Time For Occurrence policies, enter the date and time of the incident. For Claims Made policies, enter the date and time that the insured discovered the event, incident, or accident which might later result in a claim being made. This date is important for establishing the applicable policy in extended reporting period/movement of retro date situations. * After a Claims Made policy has been terminated, any claim may be valid if the incident occurred during the life of the policy and was reported within 60 days of its termination. Date of Claim This applies only to Claims Made policies. It is the date on which the actual suit was brought or claim filed against the insured. In many cases, this will be the same date that the insured first becomes aware of the incident, so both dates can be the same. Previously Reported Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If it is not the first, list in the remarks section when other report(s) have been made. Effective Date Date on which the terms and conditions of the policy commenced. Expiration Date Date on which the terms and conditions of the policy will or have expire(d). Policy Type Indicate whether the policy is written on an Occurrence or Claims Made basis. Retroactive Date

This applies to Claims Made policies only. Enter the retroactive date indicated on the policy. Company Name of the applicable insurance company and its' NAIC number. Do not use group names, use the actual name of the company within the group to which you are sending the loss notice. Miscellaneous Info Miscellaneous Information. Use this field to list site and location codes for large accounts or to enter the claim number on a phone-in report. Policy Number Number assigned by the insurance company for the policy. Reference Number Insured's claim number or other reference number to identify this notice. INSURED Name & Address Enter the name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if applicable,) of the insured as found on the declarations page of the policy. Residence Phone For an individual, the home telephone number, including area code, of the insured. Business Phone The business telephone number, including area code and extension of the insured. CONTACT Contact Insured If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address and phone number. Person to Contact Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the "Contact Insured" option is checked. Enter the home telephone number, including area code, of the contact named above. If it is the insured, leave this blank. Business Phone Enter the business telephone number, including area code and extension, of the contact. If it is the insured, leave this field blank. Where to Contact Indicate where this person should be contacted (e.g., home, office, hospital). When Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). OCCURRENCE Location of Occurrence Give the physical location of the occurrence. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured's home or Loc 3, BLd 2; 151 Main St). Authority Contacted Enter the name of the municipal or county police or fire department to which the loss was reported. Include the precinct or station number if available. Description of Occurrence Describe the incident resulting in a potential loss to the insured. POLICY INFORMATION Use this section to list the policy limits and deductibles as printed on the declarations page for the insured. Coverage Part or Forms Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, include a brief description of the endorsement.

Limits Enter the limits for each applicable category. If coverage is not provided, enter N/A. Abbreviations are: PROD./COMP-OP AGG.. . . . . . . Products/Completed Operations Aggregate PERS. & ADV. INJ . . . . . . . . . . . Personal and Advertising Injury Deductible Enter the dollar amount of the deductible and indicate whether it applies on a Per Claim or Per Occurrence basis. Deductible Type If the deductible applies to Property Damage (PD) or Bodily Injury (BI) check the appropriate box. For Combined Bodily Injury and Property Damage deductible, check PD & BI. Umbrella/Excess Indicate if such a policy is in force by checking the appropriate box. Carrier The name of the Umbrella/Excess policy/carrier. Enter the umbrella or excess policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the applicable self insured retention or deductible. TYPE OF LIABILITY This section is used to collect information about the type of exposure which has resulted in the damage or injury reported in this notice. Premises: Insured is Indicate the relationship of the insured to the premises by placing an "X" in the appropriate box. List the type when "Other" is checked. Type of Premises Give a brief description of the premises (e.g., mercantile with apartments). Owner's Name & Address If other than the insured, provide the owner's name and address. If this is the insured, enter "insured." Owner's Phone If other than the insured, provide the owner's telephone number, including area code and extension. Products: Insured Is For products coverage, indicate the business the insured is in by placing an "X" in the appropriate box. List the type when "Other" is checked. Type of Product Give a brief description of the insured's product (e.g., automobile parts, sales, appliances repair). Manufacturer's Name & Address If other than the insured, enter the manufacturer's name and address. If this is the insured, enter "insured." Manufact Phone If other than the insured, list the manufacturer's telephone number, including area code and extension. Where Can Product Be Seen? Indicate where the product can be inspected by the adjuster. If other than the insured's address, include the address. Other Liability Including Completed Operations Provide any additional pertinent information on the liability exposure. Also list any additional liability insurance carried by the insured. Include carriers, policy numbers, and limits. INJURED/PROPERTY DAMAGED Use this section to collect information on any injured party or any property damage. Name & Address Enter the name and address of any injured party, or owner of damaged property. Phone

Enter the telephone number, including area code, of any injured party or owner of damaged properties. Age Give the age of any injured person. Sex Indicate by "F"-Female or "M"-Male. Occupation Enter a brief description of the injured person's occupation. Employer's Name & Address Enter the name and address of any injured person's employer. Phone Enter the employer's telephone number, including area code and extension. Describe Injury Give a brief description of the injury. If fatal, check the available box. Where Taken Indicate where the injured was taken (e.g. St. Luke's Hospital, home). What Was Injured Doing? Briefly describe the activities of the injured person when the accident took place. Describe Property Give a brief description of any damaged property (e.g. printer # 31). Estimate Amount If known, give an estimate for the cost of repair to the damaged property. Where Can Property Be Seen? Indicate where the damaged property is located so the adjuster can inspect it. When Can Property Be Seen? Indicate the best time of day to inspect the damaged property (e.g., evenings, days, noon to 3:00 P.M.). WITNESSES Use this section to identify any witnesses to the incident. Name & Address Enter the name and address of any witness. Business Phone Enter the witness's business telephone number, including area code and extension. Residence Phone Enter the witness's residence phone number, including area code. Remarks List any other additional information that will assist in properly reporting and settling this claim. Reported By Indicate the name of the individual who reported the loss. Reported To Indicate the name of the individual within the agency or company to whom this loss was reported. Signatures of Producer and Insured This form should be signed by the producer and the insured. * Important state information is on the second side of this form.

General Liability Section 126-N (3/93)

This edition of the General Liability Section has, in most cases, been superseded by the ACORD 126-S. The ACORD 126-N is still used for risks containing commercial liability coverages not using the ISO policy simplification format. All other risks should use the ACORD 126-S. The instructions within this chapter contain only information on completing data (within the Coverage/Limits section and the Schedule of Hazards section) that differs from the data on the ACORD 126-S. For instructions on the additional sections of this form and general information on using the General Liability Section, please refer to the chapter on the COVERAGES/LIMITS Coverages Indicate all desired coverages. Comprehensive General Liability Indicate if Comprehensive General Liability coverage is being requested. Owners, Landlords & Tenants Indicate if this coverage was requested. Manufacturers & Contractors Indicate if the coverage is being requested. Storekeepers Liability This coverage is written on a combined single limit basis and requires a separate limit for Premises Medical. Owners & Contractors Protective Indicate if this coverage is being requested. Contractual Indicate whether coverage is to be provided on a Blanket basis or for Designated contracts. Describe all agreements in the Contractual section on the reverse side. Products/Completed Operations Indicate this coverage if written on either a stand-alone basis or as part of the Comprehensive General Liability coverage. Options Indicate all desired coverage options. Available options are: Broad Form Property Damage - Also, indicate if this coverage will include or exclude Completed Operations. Broad Form C G L Endorsement - This endorsement differs throughout the industry in terminology and content. Please check the company policy. Include X/C/U - X = Explosion, C = Collapse, U = Underground work. Fire Legal Liability Specify the locations to be covered and the limits applicable to each location. Elevator Collision Enter the number of elevators if required by the company. Non-Owned Auto Indicate the territory and the number of employees in the Other Coverages section. (Coverage is intended only for risks having incidental auto exposures. It will usually be more appropriate to arrange this coverage under an Auto Policy.) Property Damage Deductible Enter the Deductible amount, if any, and indicate whether it will apply Per Claim or Per Occurrence. Bodily injury deductibles are not used with any frequency, however if one applies, enter the information at the bottom of the Options section. Limits The limits as they are to appear on the policy declarations page. Bodily Injury The bodily injury limit for each occurrence and the aggregate limit for all losses occurring during an annual policy period. The aggregate limit applies only to Products, Completed Operations and Professional Liability. Property Damage The property damage limit for each occurrence and, if applicable, the aggregate limit for all losses applying to each project and occurring during an annual policy period. Combined Single Limit The combined single limit of liability, if applicable. Premises Medical The limit for each person and the limit for each accident. Personal Injury

The aggregate limit of liability for all losses occurring during an annual policy period. Check the applicable coverage. A = False Arrest, Detention or Imprisonment or Malicious Prosecution B = Libel, Slander, Defamation or Violation of Right of Private Occupancy C = Wrongful Entry, Eviction or other Invasion of Right of Private Occupancy Indicate the Insured's participation and if exclusion C is to be deleted. Other Coverages and/or Endorsements Enter any additional coverages or endorsements that are desired. SCHEDULE OF HAZARDS Complete the Schedule of Hazards in the same manner as documented for the ACORD 126-S. Scheduled classes should be separated into the following categories: Premises & Operations Escalators The premium basis is per landing. Independent Contractors The premium basis is by total estimated annual cost for the work performed by others. Contractual The premium basis tracks the number of contracts and the total estimated cost of the contracts. Products/Completed Operations The premium basis is based on receipts.

Glass and Sign Supplement 144 (11/94)

This chapter provides basic instructions for completing the ACORD Glass and Sign Supplement which addresses basic underwriting and rating needs for glass and sign coverages written under an Inland Marine or Property policy. The applicant should describe the "glass" or "sign" in detail, including lettering, ornamentation, class, mechanical operation and other important information which aids in the total evaluation of the risk. Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. INFORMATION SECTION Applicant (first Named Insured) Applicant's name as found on the ACORD 125. Glass Deductible For glass coverage, enter the deductible amount desired. Glass Retention Amount of liability retained by the insured. If applicable, enter the retention percentage. Sign If sign insurance is requested, check the appropriate box to indicate whether full coverage or coverage with a deductible is desired. GLASS SCHEDULE Complete this section and the General Information section for glass coverage. Premises Number Premises number where the glass is located. This may also appear on the Application Information Section (ACORD 125). Building Number Specific number for the building if more than one building exists at the premises location. Item Number List each piece of glass to be scheduled by assigning it an item number. Plates with the same dimensions and description can be batched under the same number. Number of Plates Number of plates of glass to be insured with the same dimensions and description. Plate Size Length (horizontal) and width (vertical) of each of plates to be insured. These should be measured in feet and inches. For odd-sized plates, you may need to compute the area (e.g., the size needed to replace a round piece of glass is a rectangle large enough to allow the circle to be cut from it).

Description Detailed description of the glass to be insured. Identify stained glass items and specify lettering, ornamentation, or class. Describe the type of frame holding each piece of glass and whether or not it is safety glass. Use and Position Use and position of glass at each location (e.g., ground floor show windows, ground floor door). This is especially important for freezer cases and display windows. Indicate what floor the glass is on and whether it is interior or exterior glass. Limit of Insurance Replacement cost of the pane, plus lettering, tape and any other item that increases the value. SIGN SCHEDULE Complete this section and the General Information Section for sign coverage. Premises Number Premises number where the glass is located. This may also appear on the Application Information Section (ACORD 125). Building Number Specific number for the building if more than one building exists at the premises location. Item Number Assign an item number to each sign to be scheduled. Inside/Outside Indicate whether each sign listed is located inside or outside a building. Different rates may apply for each. Description Detail the kind and size of the sign to be insured. Specify any lettering or ornamentation including whether the sign has mechanical parts or lighting. Specify neon light, electrical, fluorescent bulbs, etc. Limit of Insurance Replacement cost for the sign. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered "Yes." The following overview lists information that should be added to the remarks section for "Yes" responses. Questions 1 - 9 apply to Glass only, Questions 10 -13 apply to Glass and Sign, and Question 14 to Sign only. 1. Are there any partial or complete painted plates? Indicate if plate glass to be insured has any design or lettering painted on it. Specify what percentage of the plate has been painted. Include the type of decoration and if hand-painted. 2. Any plates fixed, glued or in angle settings? Indicate which, if any, plates are fixed, glued, or in special angle settings. 3. Any obstruction or unusual settings? Indicate if glass has any obstructions or has other unusual features that make replacement difficult, or if the frames are unusual. Both situations can make it difficult or costly to repair/replace. 4. Does applicant wish to insure tape on glass? If so, specify type of tape and value. 5. Does applicant wish to insure lettering on glass? Indicate if applicant has special lettering to be insured. Specify type of lettering and give approximate value. 6. Is glass protected by wire mesh or U.L.-approved burglary resistant glazing material? Indicate the security measures taken to protect the glass. 7. Is all exterior glass above second floor? Indicate which panes are located above the second floor. 8. Is all exterior glass insured? Indicate what panes are not being insured and their floor location. 9. Is any glass structural? Indicate which panes are part of the building structure. 10. Is the building or area under construction? Indicate whether there is construction or renovation taking place at any location. 11. Does glass or signs have scratches, cracks or defects? Describe any defects in the glass or sign at the time of this application. Indicate whether any corrective measures are underway. Provide diagram, if required, and specify location of glass.

12. Did agent inspect signs or glass? Indicate the inspection date and location. If a photograph is available, please attach. 13. Are any locations with glass or signs vacant? Indicate which locations are vacant and when occupancy is expected, and if any security precautions have been taken to protect the premises. 14. Any signs off premises or not attached to building? Specify location and type of protection provided for the sign. Indicate if any signs to be covered are not attached to building locations described in the Applicant Information Section (ACORD 125). Give location of signs. REMARKS Use this section to provide any additional information required for underwriting or rating.Use this space for your notes.

Good Student/Driver Training 91 (3/93a)

Auto Supplemental Forms The Good Student/Driver Training (ACORD 91), Medical Statement (ACORD 92) and the Young Driver Questionnaire (ACORD 93) are to be used when required as supplements to the auto application. The identification section of each form must be fully completed so that it can be matched to the auto application and file. This form can be used for two purposes: to qualify for a credit/discount for achieving a good student status in school, or for completing driver training instruction. An operator can qualify for both credits. Please check with the company on whether one or both credits are available. This form is generally used for operators age 21 or younger.

Homeowner Application 80 (4/2001)

The underwriting process for any personal lines policy begins with submitting a completed application. This guide assists in completing the ACORD Homeowner Application. The ACORD Personal Inland Marine Application (ACORD 81) should be used for scheduling personal property which is being submitted as part of the Homeowner Application. The Generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide.On the ACORD website (www.acord.org), , this information appears under the title PERSONAL LINES GENERIC SECTIONS. APPLICANT INFORMATION Previous Address Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address. Location of Property if Different From Above Enter the physical address of the property to be insured only if it is different from the mailing address listed above. Applicant's/Co-Applicant's Occupation Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed. Applicant's/Co-Applicant's Employer Name and Address Name and address of the organization that employs the applicant(s) named in the identification section. Yrs in Curr. Occ. Number of years in current occupation or business. Yrs w/Curr. Empl. Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section. Yrs w/Prior Empl.

Number of years with the prior employer. Mar Stat Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . .Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Birth date of each named applicant (MM/DD/YY). (E.g., March 7, 1944 should be 03/07/44.) Social Security # Social security number for each named applicant. Questions Relating to Knowledge of Applicant and Inspection of Property Indicate how long the applicant is known to the agent, and the date of the last property inspection. COVERAGES/LIMITS OF LIABILITY/ENDORSEMENTS/PAYMENT PLAN Enter the anticipated dollar limit and premium charge for each applicable coverage. List any optional endorsement(s), corresponding limit(s) and any endorsement information that is to be included in this policy. HO Form Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are: 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents 4A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Tenants 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Condominium 6A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Condominium. Deductibles Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) Premium Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit. Payment Plan Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment. RATING/UNDERWRITING Provide the information below for each dwelling. Construction Type Check the primary type of building material used to construct the dwelling. Yr Built Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alterations in the Remarks section. Also complete the Renovation Update section. Sq Ft Dwelling's total square feet of living area. # Rooms Total number of rooms in a residence, including full and half rooms (bath). # Apts Complete only for Tenant or Condominium policies. Enter the number of apartments (residences) in the building. Market Value

Estimated total dollar amount for which the dwelling could be sold under current market conditions. Replacement Cost Estimated total dollar amount required to rebuild the dwelling without depreciation. Structure Type Indicate the residence type. The full meaning of each abbreviation is: DWELLING . . . . . . . . . . . . . . . . . . . Intended to be a free standing, up to 4. . family building. APART . . . . . . . . . . . . . . . . . . . . . . . Apartment. CONDO . . . . . . . . . . . . . . . . . . . . . . Condominium. CO-OP . . . . . . . . . . . . . . . . . . . . . . . Co-operative. Usage Type Applicant's use for the dwelling within the guidelines listed. ("COC" refers to dwellings in the "course of construction".) # Families Number of separate family units in the dwelling. Not required for HO-4 or HO-6. # Hsehold Res Number of residents in the household. Purchase Date/Price Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format. # Units in Fire Div Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of fire divisions in the structure, and the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved fire walls. Terr Code Location of the dwelling based on individual state bureau or company Homeowner's Manual pages. Prem Group Premium Group is a combination of Protection Class, Territory Code and Construction Type Code and determines the applicable rate based on the dwelling's location, construction and fire protection code. The codes are found in individual state homeowner's manuals. Some companies require this data; others generate it. Protect Class Dwelling's four-character fire protection class found in individual state homeowner's manuals. Distance to Hydrant Distance (in ft.) from the nearest hydrant that supports the protection class used. Distance to Fire Station Distance in miles from the nearest fire station that supports the protection class used. Fire/EC Rate Complete if residence is specifically rated. Refer to company rate manual. Fire District/Code Number Dwelling's fire district name and corresponding five-character code number which can be found in individual state homeowner's manual pages. Protection Device Type For temperature, smoke or burglar alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies. Heat Type Type of heating device for the residence. If there is no heat in the residence, check the box. If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. If fuel storage tanks are located on the premises, describe the type and indicate the location. Possible types include: · Electric - Permanent/Portable · Natural Gas · Liquid Propane - Permanent/Portable · Oil - Permanent/Portable · Kerosene - Permanent/Portable

· · · · ·

Solar Coal - Professionally/Non-Professionally Installed Wood Other - Explain the heating system in Remarks section Central Heating

Oil Storage Tank Location If the fuel type is oil, provide the location of the fuel oil storage tank. Examples: · Indoors completely above ground on a masonry floor · Indoors completely above ground not on a masonry floor · Outdoors and completely above ground · All other (including underground) Also show the distance from the dwelling, if the storage tank is outdoors. Renovation Type If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year. Dwelling Location Location of the dwelling within the guidelines listed. Occupied By Check the applicable box to indicate occupancy by owner or tenant. Deadbolt If all entry (exterior) doors are fitted with deadbolt locks, check the box. Smoke Detector If the dwelling is equipped with smoke detector(s), check the box. Fire Extinguisher If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space. Visible to Neighbors If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box. Housekeeping Condition Enter an evaluation of the interior upkeep of the dwelling. Sprinkler If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system. Swimming Pool If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board or approved fence. Storm Shutters Check the applicable box. Hurr Res Glass Check the applicable box with respect to hurricane resistant glass. Bldg Code Grade Enter the ISO Building Code Grade, if applicable. Tax Code Enter the city, county or state tax code, if required. Rating Check the appropriate box to indicate if class rating or specific rates apply. Occupied Daily Check the appropriate boxes.

# Weeks Rented Number of weeks the dwelling is rented by the insured to others. If any apartment is rented on less than an annual basis, describe the terms.. Wind Class Check the applicable box. Roof Type Enter the material used to construct the roof. Examples: · Composition (fiberglass, asphalt, etc.) · Metal · Poured · Slate · Tile · Wood Shake/Shingle · Other ñ If used, explain in Remarks Foundation Check the applicable box. If Replacement Cost coverage applies, check the appropriate box if an ACORD replacement cost worksheet has been used (i. e., ACORD 40, 41, or 42.) Also provide the square footage of any basement, garage and breezeway. Rating Credits Check the applicable box(es) if any rating credits apply. Fireplaces Check the applicable box(es) to describe the fireplace(s.) GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response (Except questions 15, 16 and 17.) 1. Any farming or other business conducted on premises? Describe the business, where business is conducted on the premises, and if applicable, whether corporal punishment or day care coverage is to be provided. 2. Any residence employees? Use the Remarks section to provide information regarding the number of employees, the nature of their employment, hours worked per week, and whether employed inside (inservants) or outside (outservants). 3. Any flooding/brush, forest fire hazard/landslide, etc.? Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph. 4. Any other residence owned, occupied or rented? Use the Remarks section to detail the occupancy or use of the other residence. If no liability coverage is requested for this residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property. 5. Any other insurance with this company? Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. If other insurance is in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal. 6. Has insurance been transferred within agency? Indicate why this insurance has been moved from the last company. 7. Any coverage declined, cancelled, or non-renewed? Explain the circumstances surrounding this situation, including the reason for the cancellation. This question cannot be asked in Missouri. 8. Has applicant had a foreclosure, repossession or bankruptcy? Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing during the specified time period. 9. Are there any animals or exotic pets kept on the premises? Use the Remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others or to other animals. 10. Is property located within two miles of tidal water?

Use the Remarks section to describe the coastal hazard, if applicable. Indicate actual distance. 11. Is property situated on more than five acres? Use the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose. 12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description. 13. Is building retrofitted for earthquake? Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest "earthquake resistant" technology and building codes. 14. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. 15-17. Renters and Condos Only. Indicate if: 15. There is a manager on the premises. 16. A security attendant. 17. The building entrance is locked. 18. Any uncorrcted code violations? Describe any violations of applicable building codes that have not been corrected. 19. Is building undergoing renovation or reconstruction? Describe the type and scope of renovation or reconstruction of any part of the building. 20. Is the house for sale? Provide the length of time the house has been for sale, and the expected sale date if known. 21. Is property within 300 ft. of a commercial or non-residential property? Describe the occupancy of any commercial or non-residential property. 22. Is there a trampoline on the premises? Describe the device. 23. Was structure originally built & converted for other than private residence? Indicate what the structure was originally built for. 24. Any lead paint hazard? Describe the location and the extent of the hazard. 25. If a fuel tank is on premises, has other insurance been obtained for the tank? Give the First Party and the applicable limit, and the Third Party and the applicable limit. LOSS HISTORY This section shows the losses this applicant has had in the past. List losses for the last three years unless the company requires a different time period. Provision is made for the applicant to initial this section. PRIOR COVERAGE Prior Carrier Provide the prior insurance company's name. Prior Policy Number/Expiration Date List the complete policy number including prefix and suffix, and the policy's expiration date. Risk New to Agency Indicate whether this is the first time this agency has written this line of business for this applicant.

ADDITIONAL INTEREST Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is held) or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.

Installation/Builders Risk 147 (2/2001)

This chapter provides basic instructions for completing the ACORD Installation/Builders Risk Section (ACORD 147). This form was designed to request Installation or Builders Risk coverage on a specific job basis or on a blanket annual or open reporting basis. The front of the form is for Open Reporting, the reverse for Specific Jobs. This form was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Most information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125-S. However, it is still important to complete the section. Many companies, for rating purposes, separate the applications by line of business. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address, telephone and fax numbers. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125-S. Proposed Eff. Date Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Prem. Adj. Indicate if the policy is to be written on a premium adjustment basis. INSTALLATION/BUILDERS RISK Check the appropriate box to indicate which coverage, Installation or Builders Risk is being applied for. OPEN REPORTING FORM Use this section when the applicant is requesting coverage on a reporting basis. COVERAGE Limit at Any Single Location

Limit of insurance for any one job site. Limit per Disaster Overall disaster limit required. Limit at Temporary Location Insurance limit required for property to be installed while held at any temporary location. The insured's own premises is frequently excluded, so indicate if the premises is owned by the insured. Transit Limit Limit of insurance for materials while they are being shipped in transit. CAUSES OF LOSS & DEDUCTIBLE Causes of Loss Indicate the specific Causes of Loss applicable to this risk. Sub Limit If earthquake, flood or an optional cause of loss is selected, list the limit applicable to the cause of loss. Deductible All applicable deductibles. TERRITORY Specify where the applicant's job sites are located, including job site name, city, county and state. RECEIPTS List the applicant's gross installation receipts for the past 12 months and the projected receipts for the next 12 months. JOBS/VALUES This section classifies the applicant's jobs. For each classification, indicate the requested values based on residential jobs and commercial jobs. Annual Number Number of jobs the applicant performed in the last 12 months. Duration Indicate the average length of time (in months) of any one job from first entry to acceptance and transfer of risk of loss to others. This underwriting information indicates if coverage extended during hurricane/storm season. # Jobs in Progress Give the maximum and average number of jobs the applicant is involved in at any one time. Cost or Value of Each Installation Indicate the maximum value, lowest value and average value at any one job site. Material Cost Indicate the percent of the total price that the material costs represents for each type of installation job. ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS Use this section to collect information on any additional interest or receiver of Certificates of Insurance. Name and Address List the Additional Interest's name and mailing address. Interest List the subject of interest along with the interest type. Identify the subject of insurance by description and/or item number, whichever is required (e.g., Job Site # 12, Mortgagee, Lot

10, Mortgagee). Certification Required If a Certificate of Insurance is required, check this box. RIGGING Describe any hoisting or lowering operations and the equipment used. State the type of material to be moved and its value. Indicate if individuals other than the applicant are involved in the operations. TRANSPORTATION/SECURITY Indicate the percentage of material usually shipped to job sites at the applicant's risk. Describe the type of job site security the applicant employs to reduce vandalism, theft or other mishaps, including items such as fences, watchmen, police and patrol dogs. Note if equipment is left in trailers and if generators are hoisted by crane at night. REMARKS Provide any additional information required for underwriting or rating. SPECIFIC JOB This side of the application should be completed when the applicant is requesting coverage for a specific job. COVERAGE - CAUSES OF LOSS & DEDUCTIBLE The Coverage and Causes of Loss and Deductible sections should be completed as stated in the Open Reporting Form section. JOB TERM/VALUES Commencement Date the job is to begin. Completion Date the job is to be completed. Contract Amount Total dollar amount of the completed job to be insured. Any requests for soft cost coverage (e.g., mortgage costs, financing fees, insurance premiums, excavation of land costs) should be identified separately since they will be covered separately. Value of Owner Supplied Property Total dollar amount of property supplied by the owner at the specific job location. If the value of such property is in addition to the contract amount, identify in the Remarks section. SECURITY Describe the type of job site security the applicant employs to reduce vandalism, theft or other mishaps, including fences, watchmen, police and patrol dogs. Note if equipment is left in trailers and if generators are hoisted by crane at night. JOB DESCRIPTION Describe the work to be performed, the job location and the building construction. Enter insured's job number in the space provided. ADDITIONAL INTEREST Complete this section as per instructions in the Open Reporting Form section. TRANSPORTATION Use this section to collect information on the applicant's transportation exposure. Amount Shipped

Total amount shipped to the job site at the applicant's risk. % Applicant's Vehicles Indicate the percentage of property shipped to the job site using the applicant's own vehicles. % by Common/Contract Carrier Indicate the percentage of property shipped to the job site by common or contract carriers. Distance Average distance involved in shipping property to the job site from its point of origin. RIGGING Describe any Hoisting or Lowering operations and the equipment used. State the type of material to be moved and its value. Indicate if individuals other than the applicant are involved in the operations. REMARKS Provide any additional information required for underwriting or rating.

Insurance Binder 75-N (12/93)

This form is still used for risks containing commercial liability coverages not using the ISO policy simplification format. All other risks should use ACORD 75-S. The instructions within this section contain only information on completing the four coverage sections. For instructions on the other sections of this form and general information on using insurance binders, please refer to the chapter on ACORD 75-S. COVERAGES PROPERTY Complete this section when binding property coverages. Type and Location of Property Type of property covered (building, personal property) and the location address for the property (e.g., Building - 123 Howard Street, Newburgh, New York). Coverage/Perils/Forms Coverages for the property being covered and any appropriate form numbers (e.g., Special Excluding Theft - CP 10 33). Amt of Insurance Amount of insurance for the corresponding property coverage. Deductible Any deductible associated with the property coverage. Coins % Any applicable coinsurance percentage associated with the property coverage. LIABILITY Complete this section when binding liability coverages. Scheduled Form If the policy is written on a Scheduled Form basis, check this box and the appropriate boxes below to indicate which liability forms the policy is being bound. Available scheduled forms are: Premises/Operations, Products/Completed Operations, and Contractual. Comprehensive Form If the policy is written on a Comprehensive Form basis, check this box. Other If binding liability forms other than those listed above, such as Professional Liability, indicate by checking the "Other" box and list the form name either in the available space. Medical Payments If binding Medical Payments coverage, check this box and list the Per Person and Per Accident Limits in the available

space. Personal Injury If binding Personal Injury coverage, check this box and the appropriate Coverage form box(es), A, B, or C. Coverage/Forms When applicable, show the coverage using the form number and/or title of the form (e.g., OL&T 0066). Form A, B, C These are Personal Injury coverage form numbers. If Personal Injury coverage is being bound, check the appropriate box(es). A = False Arrest, Detention or Imprisonment, or Malicious Prosecution. B = Libel, Slander, Defamation, or Violation of Right of Private Occupancy. C = Wrongful Entry or Eviction or other Invasion of Right of Private Occupancy. Limits of Liability Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts.

Insurance Binder 75-S (1/2001)

This guide provides basic instructions to complete the ACORD Binder forms. The descriptions explain the information needed to properly issue a binder. The ACORD Insurance Binder addresses both Personal Lines and Commercial Lines risks, although most ACORD Personal Lines applications contain a "built-in" binder. For Commercial Lines, the layout format within the General Liability Section of the ACORD 75-S is customized to the ISO Policy Simplification program. This allows for binding of both Claims Made and Occurrence policies. The format of the ACORD 75-N follows the older, non-simplified format. Before issuing any binder, the following important considerations should be reviewed and considered carefully: A Binder (Cover Note) is a temporary insurance contract which provides coverage and must be underwritten as an insurance policy. The improper use of binders has become a major cause of producer's Errors and Omissions claims. It is imperative that only authorized people prepare them. Preparation must be complete and accurate. All binders must conform to the state insurance code for the state in which the subject of insurance is located. The maximum and/or minimum term of a binder may be governed by state statute and/or company underwriting instructions. At the end of the binder's specified term, all coverage expires unless a new binder has been issued or the expired binder has been replaced with a policy. The language in the binder must be precise. Do not use vague or all-encompassing terms which may imply coverages not intended, such as "All Risk." If possible, use the same language and terminology that will appear on the policy. An agent may only issue binders which comply with the company's underwriting instructions (per company manual, agency agreement, correspondence and/or company underwriter). If the authority is not in writing, the agent should obtain written authority. Most agency agreements contain stated "time frames" within which the company must be notified of any risk bound. Generally, a broker cannot bind insurance. A broker may only exercise the authority extended by the company. It is recommended that individual binders be issued for each company affording coverage. Most agency agreements dealing with surplus lines and specialty market contracts do not allow the agent or broker to bind coverage. Authorization must be secured prior to binding. A binder provides coverage for a specified period. In most jurisdictions, a premium must be charged for this period unless the binder is replaced by a policy or endorsement. A deposit should be obtained when issuing a binder. A deposit premium may be required by some companies. * Most companies prohibit issuing or extending binders where coverage has been refused or cancelled by any carrier. Limits All Limits should be listed as whole dollar amounts. Enter Limits corresponding to those found on the policy declarations page. IDENTIFICATION SECTION Issue Date Month/day/year on which the form is completed. Producer Name and address of the producer or broker issuing this form. Phone (A/C, No, Ext) The producer's telephone number. Code

Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company. Use the actual name of the company within the group to which this binder is being issued. Do not use group names. Binder No. Control number assigned to the binder for referencing purposes. If created by the agent, this number should be sequential and tracked within the Binder Log (ACORD 76). It may also be assigned by the company, in which case it might be the actual policy number. For control purposes, the number should be tracked within the Binder Log. Effective Date Date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy. Effective Time Time when the binder commenced. Check the appropriate AM or PM box associated with this time. Expiration Date Date on which the terms and conditions of the policy will or have expired. Certain state laws limit the terms of a binder, so this date may not coincide with the policy expiration date. Expiration Time Check the appropriate time of 12:01 AM or Noon when the binder expires. This Binder is issued to extend coverage in the above named company per expiring policy # Check the available box and enter the policy number of the expiring policy. Use this option to extend coverage on a policy where renewal is not yet available. Insured Name of the insured and mailing address requested or found on the declarations page of the policy. The line within this field is a margin setting used for window envelopes. Description of Operations/Vehicles/Property Outline the operations of the insured, vehicle information and usage, and, for property exposures, location information. Examples: Machine Tool Die Casters 91 Chevy H10 Pick Up Truck - VIN C12345P8991, used for delivery Location 1 - 123 North Main St, Hartford, Ct If the location is the same as the mailing address, and this address is properly descriptive, state "same as mailing address," rather than repeat the address. COVERAGES All limits should be listed as dollar amounts. PROPERTY Complete this section when binding property coverages. Causes of Loss Check the appropriate box to indicate the Cause of Loss for which the property coverage is being bound. For options outside of Basic, Broad, or Special (Spec.), such as Special Excluding Theft or Homeowners, enter the coverage name in the available space. Coverage/Forms Subjects of insurance that are being covered and any necessary location information (e.g., Loc 1 Building Personal Property Dwelling). Coins % Any applicable Coinsurance percentage associated with the corresponding subject(s) of insurance. Amount Corresponding amounts of insurance for the corresponding subject(s) of insurance. Deductible Any deductible associated with the corresponding subject(s) of insurance. GENERAL LIABILITY Complete this section when binding general liability coverages.

Commercial General Liability Check this box for Commercial General Liability (CGL) and the corresponding box to designate the type of policy issued Claims Made or Occur. (Occurrence). Owners & Contractor's Prot Owners & Contractor's Protective (OCP); Check this box if this is an OCP policy. Other General Liability Coverages Liability coverages not found on the form may be listed in the last two option boxes. The coverage type should be listed next to the available box (e.g., when binding Comprehensive Personal Liability, check the first box and insert "Comprehensive Personal Liability" on the line after the box). Coverage/Forms For Commercial Lines policies, enter the classification code(s) and description of the class(es) for which the binder is being issued. Include any form numbers. For Personal Lines enter the policy form numbers. Retro Date For Claims Made If the Claims Made option box is checked, and there is a retroactive date, enter the date. If there is no retroactive date, enter "none." Limits Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts. Abbreviations Products Comp/Op Agg = Products Completed Operations Aggregate Personal & Adv. Injury = Personal and Advertising Injury Med. Exp = Medical Expense AUTOMOBILE LIABILITY Complete this section when binding automobile liability coverages. Indicate which classes of vehicles are being bound by checking the appropriate boxes. Available options are: Any Auto, All Owned Autos, Scheduled Autos, Hired Autos and Non-Owned Autos. If coverage is for scheduled autos only, attach a list of the vehicles with their appropriate coverages. If other automobile coverages are desired, use the optional box and write the coverage name next to the box. Coverage/Forms List any policy form numbers in this section. Limits Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts. Use the optional limit line to list any coverage not specifically listed, such as Additional Personal Injury Protection (APIP). AUTO PHYSICAL DAMAGE Complete this section when binding automobile physical damage coverages. If physical damage coverage is being bound, use the appropriate box to indicate Collision or Other than Collision coverage. List any deductibles in the available space. All Vehicles/Scheduled Vehicles Indicate if collision coverage applies to all or only scheduled vehicles. Valuation Type Check the appropriate box to indicate what basis is to be used for determining the vehicle's value. Options are: Actual Cash Value, Stated Amount and Other. For "Other," list the valuation type in the space provided. Limit List the combined sum of the vehicle's physical damage valuation. GARAGE LIABILITY Complete this section only if you are binding garage liability. Use the available lines or the "Any Auto" option to indicate coverage specifics. Coverage Forms List any applicable coverage form numbers. Limits Complete the limits found on the Garage declarations page. EXCESS LIABILITY Complete this section when binding some type of excess liability policy. For Umbrella policies, check the appropriate box. If the Other Than Umbrella box is checked, an additional reference should be made in the Coverage/Forms section stating the kind of policy and to which coverages the policy applies (e.g., Excess - Auto section). Retro Date For Claims Made

If this is a Claims Made policy and there is a retroactive date, enter the date. If there is no retroactive date, enter "none." Limit Complete the limits in accordance with the policy declarations page. Workers Compensation and Employer's Liability Complete this section when binding workers compensation and/or employer's liability policies. If the policy being bound is written using Statutory Limits, check the appropriate box. If Employers Liability is included, show the limits for "Each Accident," "Disease-Policy Limit," and "Disease-Each Employee." Special Conditions/Other Coverages Provide any additional information pertinent to the bound policies. Include any special endorsements that are not specified in other sections of the binder. The area can also be used to add other coverages, refer to other binders, acknowledge receipt of deposit premium, or show fees, taxes and/or estimated premium. NAME & ADDRESS This section tracks any additional interest to the policy. Name & Address Complete name and address of an additional interest if any have been indicated. The line within this section is a margin setting used for window envelopes. Interest Type Check the additional interest's type in the appropriate box. Options are: Mortgagee Loss Payee Additional Insured Other. Loan # List any loan number, account number or other controlling number that the additional interest may have assigned the insured. AUTHORIZED REPRESENTATIVE Binders must be signed by authorized representatives of the issuing company.

Automobile Insurance ID Card 50 (1/83)

The ACORD Automobile Insurance Identification Card (ACORD 50) is accepted in the majority of states that require the insured to carry/produce upon demand proof of insurance. The ACORD Automobile Insurance Identification Card (ACORD 50) is accepted in the majority of states that require the insured to carry/produce upon demand proof of insurance. The states where ACORD 50 is not acceptable are: Delaware Michigan Florida Oklahoma Hawaii Mississippi Texas Kentucky West Virginia Louisiana For the states listed above, refer to the State Forms section of this manual. Specific ID cards are provided for each state, and information about each ID card is provided. Each completed ACORD 50 ID card should include the appropriate state title on the top line before Insurance Identification Card. The card is available in single sheets and two part sets to correspond with different states' specifications for the number of copies required to be produced. Some states require additional wording and/or supplemental information when ACORD 50 is issued. Information on these states follows. ACORD 50 WM may also be used in all states where ACORD 50 is acceptable. This card contains a watermark (the word "ACORD") which is invisible when the form is photocopied. This feature helps to prevent fraudulent reproduction. Special Provisions/State Exceptions to ACORD ID CARD (ACORD 50). California Wording: "The policy meets the requirements of Section 16056 of the California Vehicle Code." Colorado Must display the coverage required by law; BI, PD, PIP (limits need not be stated).

Connecticut Add the following wording: "Connecticut Insurance Card issued pursuant to Connecticut Law." This text should appear under the pre-printed words Insurance Identification Card. Issue in duplicate. Expiration date must be one year from effective date. Idaho Title should be either Certificate of Liability or Liability Insurance Identification Card. Inclusion of "State of Idaho" is optional. Illinois Add the following wording: "Examine policy exclusions carefully. This form does not constitute any part of your nsurance policy." Indiana Financial Responsibility filing only. Kansas Cannot be used by those vehicles subject to the State Corporation Commission. Maine Title should be "Maine Motor Vehicle Insurance Identification Card." The following should also be added to the card (may be added to the reverse side): "The policy provides the minimum insurance required by law." Mississippi This auto ID card was developed in response to Mississippi law requiring that all vehicles after 1/1/01 must have proof of insurance in the vehicle. Minnesota Plain language summary must accompany the card but does not have to be printed on card. The following language is advisory and can be modified: "Pursuant to M.S. 65B.67; failure to provide proof of insurance at the request of a law enforcement official or within 14 days is a misdemeanor punishable by a $700 fine and/or 90 days in jail, and revocation of driving privileges." Nebraska Title: Nebraska Auto Liability. Nevada Title: Evidence of Motor Vehicle Liability Insurance. Add the following wording: "This card approved by the Nevada Insurance Commisioner" (on front side). Suggest issuing in duplicate since one copy is rendered to the Department of Motor Vehicles when registration is renewed. New Jersey If the card is being used for coverage under the New Jersey Automobile Full Insurance Underwriting Association, wording must appear on the front to that effect. Also: only two sided, preprinted ACORD 50 or ACORD 50WM are acceptable The following should be added to the back of the card: Insert address for notification of commencement of medical treatment." Pennsylvania Title: Financial Responsibility Identification Card. Expiration Date: Not Valid More Than One Year From Effective Date. ACORD Card must be accompanied with the instructions set forth in section 67.25 of the insurance department regulations, 14 Pa.B.2949. (These instructions must also accompany any other identification card issued under the Financial Responsibility Law.) Rhode Island Add the following wording: "Policy meets Rhode Island limits." South Carolina Add the following wording: "Coverage meets SC minimum financial responsibility requirements." South Dakota Issue in duplicate. Title: Add the following wording: "Coverage provided by this policy meets the minimum liability limits prescribed by law." Vermont Title: "Vermont Automobile." Add the following wording: "Policy provides the minimum insurance prescribed by law." Michigan Certificate of No-Fault Insurance 50MI (6/93) The Michigan Certificate of No-Fault Insurance Card was created to satisfy Michigan statutory and regulatory requirements with respect to proof of no-fault insurance coverage. The part of ACORD 50 MI which includes the statement "Secretary of State Copy" should be used by the insured to apply for vehicle registration. The other part must be kept in the insured's vehicle at all times. New York State Insurance Identification Card (1/98) Use ACORD 50 NY to comply with New York State Department of Motor Vehicle regulations. This card is identical to the New York State Insurance Identification Card FS-20. This card may only be issued by an authorized representative of a licensed New York state insurer.

ACORD 50 NY is printed on watermarked paper (the word "ACORD" is the watermark). For agents or companies that will print copies of 50 NY from their software systems, ACORD 360 WM is watermarked paper that can be ordered from ACORD. This paper can be used to satisfy the watermark requirement. Delaware Auto Insurance I.D. Card 50WM (2/95) This card includes a watermark which is invisible when the form is photocopied. This feature is intended to help prevent fraudulent reproduction. ACORD Form 50 WM must be used in Delaware. It may also be used in lieu of ACORD Form 50, in any state where ACORD 50 is accepted. Florida Auto Insurance Identification Card 50FL (3/94) The Florida Auto Insurance Identification Card was created in response to Florida regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Florida card are: The size of the card is 3 1/2 inches wide, 2 1/4 inches high (wallet size) Boxes referring to Personal Injury Protection Benefits/Property Damage Liability and Bodily Injury Liability must be checked, according to the coverage provided Statements are included on the back of the card, referring to the providing of Rental Car Coverage, and the fact that misrepresentation of insurance is a first degree misdemeanor Oklahoma Security Verification Form 50OK (3/94) The Oklahoma Automobile Insurance Identification Card was created in response to Oklahoma regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Oklahoma card are: The address of the insured cannot be shown on the card The front of the card includes a series of letters of the alphabet that correspond to pre-printed coverages shown on the back of the card. The appropriate letters must be checked or circled to indicate actual coverage in the policy The front of the OWNERS FORM states that a liability insurance policy has been issued pursuant to the compulsory insurance law of Oklahoma and that this form must be kept in the vehicle at all times The back of the OWNERS FORM contains a statement describing Oklahoma state law with respect to the use of the requirement that this form be produced upon request by a peace officer, or representative of the Department of Public Safety or, in case of an accident, other persons affected by the accident The second part of ACORD 50 OK, which includes the statement "submit this part with your application for registration", should be used to apply for vehicle registration Hawaii No-Fault Insurance Identification Card 50HI (1/99) The Hawaii Automobile Insurance Identification Card was created in response to Hawaii regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Hawaii card are: The size of the card is 3 1/2 inches wide by 2 1/4 inches high (wallet size) A statement is added to the front of the card referencing an authorized Hawaii insurer who issued an insurance policy which complies with Hawaii's motor vehicle insurance law The order of entries on the front of the card is prescribed by regulation The card is printed on watermarked paper. The watermark is the word "ACORD." Commonwealth of Kentucky Proof of Insurance 50KY (3/98) The Kentucky Automobile Insurance Identification Card was created in response to Kentucky regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Kentucky card are: The size of the card is 3 1/2 inches wide and 2 1/4 inches high (wallet size) The order of entries on the front of the card is prescribed by regulation State mandated "Instructions to Policyholder" are included on the back of the card Two copies of this ID card must be given to the insured. One will be used to present to the county clerk when renewing motor vehicle registration; the other must be carried in the identified motor vehicle. Louisiana Automobile Insurance Identification Card 50LA (4/96) The Louisiana Automobile Insurance Identification Card was created in response to Louisiana regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Louisiana card are: The company NAIC number and name and address must be shown on the front of the card. The explanation of penalties for failure to comply with statutes and regulations is revised A statement is added to the front of the card referencing an authorized insurer who has issued a motor vehicle policy with coverage that meets the minimum liability limits prescribed by law The back of the form contains an Important Notice, required by regulation, that explains Louisiana compulsory insurance requirements, and the possible penalties for failing to comply The name, address and telephone number of the insurance agent, and a list of any excluded drivers, must appear on the back of the form. Missouri Auto Insurance Identification Card (2/98) This ID card was created in response to Missouri law. The main differences between the generic ACORD Auto Insurance Card, ACORD 50, and the Missouri card are: Space is provided on the front of the card for the name and complete address of the insurance carrier The text of the "use" statement on the back of the card is revised to comply with Missouri law.

Texas Liability Insurance Card 50TX (2/97) The Texas Liability Insurance Card was created in response to the Texas State Board of Insurance Order No. 58994 which became effective September 1, 1991. The Texas Liability Insurance Card is similar in data content to the generic ACORD Automobile Insurance Card. The main difference between the two cards is that Texas requires: A Spanish translation of the text A toll free phone number of the insurer for consumer inquiries The Motor Vehicle Safety-Responsibility text West Virginia Certificate of Insurance 50WV (3/94) The West Virginia Automobile Insurance Card was created in response to West Virginia regulations. The main differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the West Virginia card are: The plate number must be shown in the upper right corner of the front of the card. The front of the card includes a statement referring to an authorized insurer who has issued a policy in accordance with West Virginia law. If the owner and the insured are different, both names must be shown. The owner must sign the form.

Automobile Insurance ID Card 50WM (2/95)

See ACORD Form 50 * ACORD 50 WM may also be used in all states where ACORD 50 is acceptable. This card contains a watermark (the word "ACORD") which is invisible when the form is photocopied. This feature helps to prevent fraudulent reproduction.

Medical Statement 92 (2/95)

This form is submitted if the applicant or another driver on the policy has a medical condition/history requiring that further information be provided to the company. Some companies require the form be submitted for all drivers over a certain age. If question #11 on the auto application has been answered "Yes", this form should be completed. The form should be completed and signed by the individual with the medical condition.

Miscellaneous Crime Coverage 151 (7/2001)

This form can be used to provide information about premises and safe protection, messengers and armored motor vehicles, additional locations, and scheduled employees where required. This form is to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION Most information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. However, it is still important to complete the section. Many companies, for rating purposes, separate the applications by line of business. Not completing this part of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address, fax and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.

Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Effective date on which the terms and conditions of the policy will commence. Expiration Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . other. PREMISES/SAFE PROTECTION Complete one section per location to describe the location's security systems. Alarm Type Indicate the style of alarm(s) for the premises safes or vaults on it. Available options are: · Hold-Up - Manual or semiautomatic control which can transmit an alarm in the event of a hold-up. · Premises - Sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The Premises Extent must be completed for Premises Alarms. · Safe/Vault - Alarm system that protects the safe or vault and is connected to outside central station, gong or siren. The Extent of Protection for Safe/Vault must be completed for all safes/vaults. Alarm Description Indicate any applicable features of the alarm. · Local Gong - Bell located outside the premises. · Central Station - Private security service which monitors the alarm system and may dispatch security officers in response to an alarm. · Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private control station. · With Keys - Indicate if security service or police have keys to respond to alarms. Grade Grade or class A, B, C, etc. which indicates the time required to respond to a signal from the alarm system. Refer to manual. Extent of Protection for Safe/Vault Indicate the extent of the alarm protection for the safe or vault. · Partial - Alarm covers around door only · Complete - Alarm covers sides, top walls, floor and ceiling. Extent of Protection for Premises Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual. Alarm Installed & Serviced By Name of the company installing and servicing the alarm system. Alarm companies often install, maintain and service the system in addition to providing Central Station facilities. # Guards Number of guards within the premises or at its door while regularly open for business.

# Watchpersons Number of watchpersons on the premises retained during non-office hours. Watchpersons Indicate the type of watchpersons reporting. · Rpt/Cent. St - Report to a central station on an hourly basis · Clock Hrly - Register hourly with an approved watchpersons' clock (Detex Time Clock, etc.) · Don't Signal - Do not do any type of reporting or registering Certificate Number Alarms approved by the Underwriters Laboratories (UL) are earmarked by a certificate. Record the certificate number; (Note: UL certification can apply to the entire system or to individual parts). Expiration Date UL certificate expiration date. Accessible Openings & Protection Provide information regarding access to the premises. Indicate number of doors and if they are protected in any manner. Indicate what type of locks are used and if there is a gate or bars. Other Protection Describe any other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm). Indicate if the building has skylights and if windows are visible from the street. PREMISES, MESSENGER & ARMORED MOTOR VEHICLE SCHEDULE Loc Applicant's premises location number as found on ACORD 125, or listed below in the Additional Locations section. # Mess'gr Number of messangers to which the limits apply. # of Arm'd Veh. Number of armored vehicles to which the limits apply. Inside/Outside Limits Any appropriate limit inside or outside the premises. ADDITIONAL LOCATIONS Use this section when the applicant is requesting coverage on locations that did not fit onto the ACORD 125 Location section. Loc # Location number to be associated with this address. This number should not be one of the numbers used on the ACORD 125. Address Applicant's address associated with this location number. EMPLOYEE SCHEDULE Use this section to specifically schedule employees. Loc # Location number where the employee works. Name of Employee Employee name that coverage is specifically being scheduled for. Title Employee's job title. Limit Specific limit scheduled to this employee. Deductible Specific deductible scheduled to this employee.

REMARKS Provide any additional information required for underwriting or rating.

Personal Automobile Application 90

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide provides assistance in completing the ACORD Personal Auto Application. The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. There are three additional, optional forms in the personal auto series: Good Student/Driver Training (ACORD 91), Medical Statement (ACORD 92), and Young Driver Questionnaire (ACORD 93). IMPORTANT - State-specific personal auto applications, together with all necessary required supplements and notices, have been provided for all states. All comply with current state statutes and regulations, and all will be revised as necessary to comply with future changes in state requirements. The original ACORD 90, Personal Auto Application, was withdrawn July 1, 1996, two years after the introduction of all of the state-specific forms. The original ACORD 90 was not acceptable because of laws or regulations in thirty-three states. However, the state-specific applications developed by ACORD to replace the original ACORD 90 are acceptable in each respective state. The unique sections of the state applications are the Coverages/Premium section on the front of the form, and the Fair Credit, Fraud, coverage acceptance/rejection, and other disclosure requirements on the bottom of the back of the form. The balance of each state form is identical to all the others. The following pages include a depiction of the common sections, and instructions relating to the completion of these sections. Refer to the State Forms section of this Guide, and your company rating manual, for information about the state-unique coverage and requirements. RESIDENCE Number of Years at Address Current and Previous Number of years present at both the applicant's current and previous addresses. Previous Address Physical address of the first named insured if the applicant has been at the current address for less than three years. GARAGE LOCATION Indicate vehicle number and complete address including ZIP code for any vehicle not kept at the mailing address. Also, provide this information if the mailing address is a post office box or rural route address, or when a driver is at school with a vehicle. VEHICLE DESCRIPTION/USE Total # Vehicles In Household All owned, leased, or regularly used vehicles in household, including non-registered and non-insured vehicles. Year Model year of the vehicle. Make, Model and Body Type Manufacturer's trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4 door sedan). VIN/Registered State Vehicle identification number as it appears on the title certificate or registration. Also enter the state where the vehicle is registered. If the vehicle is registered in a state different from where it is garaged, provide an explanation in the Remarks section. HP/CC Horsepower, or the number of cubic centimeters of displacement. Date Purch Year the applicant acquired the vehicle in YYYY format. New/Used Enter "N" if the applicant bought the vehicle new, "U" if the vehicle was used. Cost New Original cost of the vehicle. Symbol Age Grp If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual.

Terr Rating territory code where the vehicle is principally garaged. Refer to rating manual. Miles 1 Way Wk/Schl Number of miles from the garage location to school or work. # Days Week Number of days per week the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station. # Weeks/ Mo. Number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station. Usage Enter pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation, profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of occupation, profession or business is considered pleasure. Perform Vehicle's performance level. Indicate High (H), Intermediate (I) or Sport (S). Multi-Car Check box only if multi-car credit applies. Carpool Indicate if any vehicle is used in a car pool for travel to work or school. Garaged Indicate if the vehicle is parked in a garage at night. If the vehicle is left on the street, at school or some other equally exposed place, provide this information in Remarks. Examples of exposures are: Off street (driveway) Off street (school) On street (at residence) On street (at school) Odometer Reading Current number of miles on the odometer. Annual Mileage Total estimated annual mileage for each vehicle. Govern Driver Driver to be assigned to each vehicle for rating purposes. Driver Use % Percentage that each driver uses each vehicle. Each vehicle should total 100 percent. If any driver has 0 percent use for all vehicles, indicate why in the Remarks section. Class Rate classification for each vehicle. Refer to manual; some companies determine class automatically from information provided in Vehicle Use and Driver Information sections. Seat Belt Check the box if the vehicle is equipped with automatic seat belts. Air Bag Indicate D for driver side air bag, B for vehicle equipped with air bag for both front driver and passenger. Anti-Lock Brakes 2/4 For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel anti-lock braking system. Anti-Theft Devices If vehicle is equipped with an anti-theft device, indicate type. Credits and Surcharges Enter any other credits and/or surcharges that are to apply to any or all vehicles. COVERAGES/PREMIUMS For information relating to each state's unique coverages, refer to the State Forms section in this guide, and your company's rating manual.

DRIVER INFORMATION Name Name of each licensed operator (resident or not) as it appears on their drivers licenses, and every resident of the household regardless of age. Enter the surname only if different from the applicant's. Show the applicant as driver #1, even if not an operator. Sex Enter F for female, M for male. Mar Stat Enter the marital status of each listed driver. Examples: S=Single M=Married D=Divorced SP=Separated W=Widowed Relation to Applicant Driver's relationship to the applicant. Examples: I=Insured Sp=Spouse C=Child Sib=Brother/Sister P=Parent E=Employee Date of Birth Date of birth of each driver and household resident (MM/DD/YY) (e.g., March 7, 1944 should be 03/07/44). Occupation Occupation of each operator. Date Lic Date (MM/YY) each driver was permanently licensed. Stdt >> 100 Indicate if any youthful driver is residing at a school over 100 road miles from the principal place of garaging. Show name of institution and address in the Remarks section. Good Stdt Indicate if any driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies. Drv Train Indicate if driver training credit applies to the driver, if required by the company. Refer to the company's manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate for any operator under age 21 who has successfully completed this training and qualifies for the credit. Acc Prev Cse Date on which the driver successfully completed an approved motor vehicle accident prevention course (or a similarly recognized defensive driving course). Attach a completion certificate for each driver who qualifies. Drivers License #/ Licensed State Complete drivers license number and licensed state for each licensed operator. Copy directly from license if possible. Social Security # Social security number for each named driver and household resident. ACCIDENTS/CONVICTIONS It is important that this section be completed fully and accurately. Many companies verify driving records with state motor vehicle departments. Discrepancies between the application and the report may result in processing delays and unnecessary correspondence with the company. If there have not been any accidents, convictions or comprehensive losses during the indicated time period, enter "None". Be sure to enter the number of years reviewed, in accordance with the company's and state's requirements, as the experience period. Drv # Driver number as found in the driver information section. Date of Accident/Conviction Date the accident or conviction occurred. Description of Accident or Conviction

A complete description of the accident or conviction. This would include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgement of guilty, plea of nolo contendere or forfeiture of bail. Use the Remarks section or an additional piece of paper if necessary. Place of Accident/Conviction City and state of the accident or conviction. BI or Death Indicate whether bodily injury or death occurred. Include details in the description of accident. Amount of Property Damage Total amount of property damage, both the applicant's and all claimant's combined damages. Refer to company manual. ADDITIONAL INTEREST Indicate if additional interest is an additional insured-lessor, certificate holder or a loss payee. Show complete name and mailing address. Provide the following information for each entity having an interest in the personal automobile(s) to be insured. The interest number or rank (1st, 2nd), whether additional interest or loss payee, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number. EMPLOYMENT INFORMATION Applicant's/Co-Applicant's Employer Name of the organization that employs the applicant(s) named in the identification section. Applicant's Employment Location Applicant's employment location. This may differ from where the main office/plant is situated. Work Phone Number Work phone number at which the applicant/co-applicant may be reached. Yrs Empl The number of years the applicant(s) have been with the employer indicated above. If less than 2 years, provide the number of years previous employment. Provide the name of the previous employer and previous occupantion in the remarks section. PRIOR COVERAGE Provide the prior insurance company's name, producer, number of years with the company, policy number and the date the prior policy expired. GENERAL INFORMATION If there are any Yes responses, provide a complete explanation in the Remarks section. Use an additional sheet of paper if the room in the Remarks section is not adequate. 1. Vehicle not registered to applicant? Provide the vehicle number and the name of any vehicle not owned by or registered to the applicant. 2. Any car modified/special equipment? Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any customized painting such as murals or pin striping, any equipment installed to overcome a physical handicap. Indicate vehicle number, a description of the modifications and the cost of the special equipment. 3. Any existing damage? Indicate if any vehicle has been damaged and not repaired as of the date of application. Indicate the vehicle number and a complete description of the damage. 4. Any other losses incurred? Any other losses, such as glass damage, vandalism, fire or theft, not shown in the Accident/Conviction section, incurred within the last three years. Provide description and amount of loss. 5. Any car kept at school? Identify the household member and the name and location of the school. Provide the distance between the school and the residence garage location. 6. Any car parked on street? Determine if any vehicle is parked on the street or kept in other than an enclosed garage when not in use. Indicate vehicle number from vehicle description area and where the vehicle is parked. 7. Any other automobile insurance? Provide the insured's name, vehicle description, insurance company, type of coverage and policy number for any other household resident's automobile insurance. 8. Any other insurance with company? Indicate the type and policy number of any other insurance the applicant has with the company. 9. Any household member in military service? Provide details on branch of service, rank, and location of base for any household member in active military service.

Determine if any vehicle is at the military location. 10. Any license suspended/revoked? Indicate the driver number, the period of suspension, the reason for suspension, and the date the license was reinstated. 11. Any physical/mental impairments? List any operator with a physical or medical impairment which could hinder the safe operation of a vehicle ( amputation, epilepsy). If impaired, enter the name of the driver, a description of any special equipment installed, and treatment or medication being administered. This question cannot be asked in some states. In those states, the question does not appear on the application. 12. Any financial responsibility filing? Indicate the driver's name, the reason for the filing, and the date of original filing. 13. Has insurance been transferred within agency? Indicate if prior carrier and previous policy number information shown on the front of the application represents a policy being transferred within the agency. If Yes, give reason for transfer. 14. Any insurance declined/cancelled? Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within the last three years. List the person's name and why the action was taken. This question cannot be asked in some states. n those states, the question does not appear on the application. 15. Is this brokered business to the agent? Indicate if the application came through a broker not part of the agency. Alabama Personal Auto Application ACORD 90 AL (2/2001) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Uninsured Motorists Bodily Injury coverage includes Underinsured Motorists Bodily Injury coverage; Uninsured or Underinsured Motorists Property Damage coverage is not available. Statement added to the back of the form referencing the explanation and offer of Uninsured Motorists Bodily Injury coverage up to the policy's Bodily Injury Liability limits, and the right of the applicant to reject this coverage. The statement must be initialed by the applicant. Alaska Personal Auto Application ACORD 90 AK (2/2001) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90, the generic Personal Auto Application, on this website. · Personal Injury Protection coverage does not apply; this is not a "no-fault"state. · A required statement has been added to the back of the form with respect to the offer of Rental Vehicle Damage coverage if Comprehensive and/or Collision coverage has been rejected by the applicant. Arizona Personal Auto Application ACORD 90 AZ (3/97) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added to the back of the form, referencing the Arizona Supplement, ACORD 61 AZ, which must be signed by the applicant. Arkansas Personal Auto Application ACORD 90 AR (10/2000) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect unique Arkansas coverages and options. Refer to your state manual. Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorists Property Damage is not available. Statement added to the back of the form, referencing the Arkansas Supplement, ACORD 61 AR, which must be used if the applicant chooses Uninsured or Underinsured Motorists Bodily Injury coverages less than the limits of the policy's basic Bodily Injury Liability limits. California Personal Auto Application ACORD 90 CA (1/2000) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage does not apply. This is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. Reference to "Waiver of Collision Deductible" is added. Statement added referring to the offer of Uninsured Motorists coverage up to the Bodily Injury Liability coverage in the policy, and the applicant's right to select lower limits, reject coverage for certain drivers, or reject UM coverage entirely. If the applicant chooses any option other than limits equal to the policy's BI limits, the California Auto Supplement, ACORD 61 CA, must be signed. Statement added referring to the offering of a Waiver of the Collision deductible. A column titled "Good DRV" is added to the Resident and Driver Information section, to recognize "Good Drivers" as required by California Law. The column titled "Defensive Driving Date" is retitled "ACC Prev CSE Date" (Accident Prevention Course Date). A General Information question (No. 15) is

added, relating to brokered business. The Fair Credit Reporting Act on the back of the form is editorially revised. The generic fraud statement is replaced by a fraud statement now mandated by California law. A statement is added to the back of the form as required by California law, advising the applicant of his or her rights with respect to "good driver" policies. Provision is made in the Applicants section to record the name of the registered owner if different from the applicant. A field to record date leased, if applicable, is added to the Vehicle Description/Use section. An instruction is added to General Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments). A new General Information question 17 is added to capture the years licensed to drive motorcycles, when such vehicles are to be insured. This complies with a new California requirement. Colorado Personal Auto Application ACORD 90 CO (1/99) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are replaced with Colorado's unique coverages and options. Refer to your state manual. Underinsured Motorists coverage is included in Uninsured Motorists coverage. Statements added referring to the explanation and offer to the applicant of Uninsured Motorists coverage, and the right of the applicant to select/reject coverage. If Uninsured Motorists Bodily Injury coverage is rejected entirely, the applicant must initial the statement. Connecticut Personal Auto Application ACORD 90 CT (10/96) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Although the Connecticut legislature revised the state's no-fault law January 1, 1994, so that these coverages are no longer mandatory, coverage can still be made available. Many companies are continuing to offer Basic Reparations Benefits and/or Added Basic Reparations Benefits (no-fault coverages). Consequently, these items are included in to the Coverages/Premium section. Uninsured Motorists and Underinsured Motorists coverages are combined. Uninsured Motorists Conversion coverage is added to the Coverages/Premiums section. This coverage can be purchased instead of Uninsured/Underinsured Motorists coverage. Full Glass Optional coverage added to Comprehensive. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Delaware Personal Auto Application ACORD 90 DE (8/98) Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agents that charge policy fees. Added instruction in the Resident and Driver Information section to show name as it appears on drivers license. At the request of the Delaware Department of Insurance, "3 years" is printed in the sentence in the Accidents/Convictions section relating to information about accidents and traffic violations. A note is added to the Employment Information section requiring that self-employed applicants state the nature of their business. An instruction is added to General Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments). Reference to "no-fault application" is removed from the Attachments section. Such forms are no longer necessary. The "Applicants Statement" on the back of the form is editorially revised. These revisions will be made to all state-specific ACORD 90 forms, but only when other specific changes must be made in the individual states. District of Columbia Personal Auto Application ACORD 90 DC (9/2000) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect D.C.'s unique coverages and options. Refer to your state manual. Statement added referencing the offer of Uninsured and Underinsured Motorists coverages, and the applicant's right to select coverage limits, and reject Underinsured Motorists coverage. Statement added allowing the applicant to reject Personal Injury Protection coverages. Applicant must signify rejection by initialing the form. Question relating to cancellation or declination of coverage is deleted; this question cannot be asked in D.C. Florida Personal Auto Application ACORD 90 FL (7/2000) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect Florida's unique coverages and options. Refer to your state manual. Underinsured Motorists/Bodily Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property Damage coverages are not available. References to "stacked" and "non stacked" options are added to Uninsured Motorists coverage. Statement added to the back of the form referencing the various Uninsured Motorists coverage options, and the use of the state supplement, ACORD 61 FL, if Uninsured Motorists, or non-stacked coverage, is rejected. The fraud statement is revised to comply with a new Florida law. Georgia Personal Auto Application ACORD 90 GA (10/96) Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage does not apply; this is not a "no-fault" state. Uninsured Motorists coverage includes Underinsured Motorists coverage; provision is made for per-accident deductibles under Uninsured Motorists coverage. Required statements have been added to the back of the form:

1. Noting if copies of the Privacy Act and Fair Credit Reporting notices have been given to the applicant 2. Referring to the state supplement containing explanation and selection options for Uninsured Motorists and Medical Payments coverages 3. Providing a statement regarding the advance payment of the first sixty days of coverage by the applicant, unless the policy is a continuation of another policy, and there has been no lapse in coverage Hawaii Personal Auto Application ACORD 90 HI (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages and options available. Refer to your state manual. The applicant can select "stacked" or "non-stacked" Uninsured and Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available. Idaho Personal Auto Application ACORD 90 ID (11/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits, and the applicant's right to select other limits, or to reject coverage entirely. Illinois Personal Auto Application ACORD 90 IL (8/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages deleted; this is not a "no-fault" state. Uninsured and Underinsured Motorists Bodily Injury coverages are combined; Underinsured Motorists Property Damage coverage does not apply; Uninsured Motorists Property Damage coverage is shown separately. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added referring to the state supplement, ACORD 61 IL, with respect to the selection of Uninsured/Underinsured Motorists Bodily Injury Liability coverage lower than the Bodily Injury Liability coverage in the policy, or the selection of Uninsured Motorists Property Damage coverage for vehicles not covered by collision insurance. Indiana Personal Auto Application ACORD 90 IN (8/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury and Property Damage coverages. The applicant must initial the statement if any coverage is rejected. Iowa Personal Auto Application ACORD 90 IA (10/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured Motorists and Underinsured Motorists coverage sections include reference to "stacked" and "non-stacked" coverages; Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the state supplement, ACORD 61 IA, the offer of various Uninsured and Underinsured Motorists Bodily Injury coverage options, and the applicant's right to select or to reject coverage entirely. If the insured decides to select "stacked" UM or UIM, or to reject either UM or UIM coverage, the state supplement must be signed. Kansas Personal Auto Application ACORD 90 KS (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages have been revised to allow for Kansas options. Refer to your state manual. Uninsured Motorists coverage includes Underinsured Motorists coverage; however, there is no Property Damage coverage available. Information relating to accidents or convictions on the front of the form is limited to the last 3 years, as is information regarding license suspension/revocation on the back of the form. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. A required statement has been added to the back of the form, advising the applicant that auto liability insurance may be available through the Kansas Automobile Insurance Plan. In addition, a statement has been added to the back of the form requiring the applicant to acknowledge available Uninsured Motorists coverage options, including the option of rejecting UM limits higher than the mandatory minimum limits. Kentucky Personal Auto Application ACORD 90 KY (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Provision is made to report the "Tax Territory" as required by Kentucky Law. Personal Injury Protection coverages are revised to reflect Kentucky's unique coverages and options. Refer to your state manual. Uninsured and Underinsured Motorists Property Damage coverages are not available. Added section to the back of the form to allow descriptions of motorcycles, and named individuals to be covered, as required under PIP options. Provided statement referencing the explanation to the applicant of Uninsured and Underinsured Motorists coverages and available options; provided space to allow the applicant to reject UM and/or UIM. The fraud statement on the back of the form is revised to reflect a new Kentucky law. Louisiana Personal Auto Application ACORD 90 LA (6/98) Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. Provision is made

to select "Economic & Non Economic" Loss coverage or "Economic Loss only" coverage in the Uninsured Motorists coverage item. Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agent sthat charge policy fees. Added instruction in the Resident and Driver Information section to show name as it appears on drivers license. A note is added to the Employment Information section requiring that selfemployed applicants state the nature of their business. An instruction is added to General Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments). The "Applicants Statement" on the back of the form is editorially revised. The statement relating to Uninsured Motorists BI and PD coverage selection and rejection is revised to refer to the new Louisiana Auto Supplement. The new supplement must be used if UMBI or UMPD coverage is rejected, or if the applicant selects UMBI coverage lower than the policy's liability limits. These revisions will be made to all statespecific ACORD 90 forms, but only when other specific changes must be made in the individual states. Maine Personal Auto Application ACORD 90 ME (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Bodily Injury coverages are combined. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the offer of Uninsured/ Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits and the applicant's right to select lower limits, or to reject coverage entirely. Maryland Personal Auto Application ACORD 90 MD (1/98) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect Maryland's unique coverages and options. Refer to your state manual. Underinsured Motorists coverage is included in Uninsured Motorists coverage. A limit of three years is added to the question relating to accidents and convictions on the front of the form, as required by the Maryland Insurance Department. Statement added to the back of the form, referencing the state supplement, ACORD 61 MD, which must be given to the applicant if Personal Injury Protection coverage is rejected, or if Uninsured Motorists' Bodily Injury coverage less than the limits of the policy's Bodily Injury Liability limits is selected. Application For Massachusetts Motor Vehicle Insurance ACORD 90 MA (1/2000) This application is entirely different than applications in other states. Therefore, all the instructions for completing the form are provided. The state of Massachusetts requires personal automobile, new business and renewals, to be submitted on forms that are prescribed by the Massachusetts Commissioner of Insurance. The ACORD 90 MA, Application for Massachusetts Motor Vehicle Insurance, meets the prescribed requirements. Questions or comments regarding this form should be directed to the Massachusetts Automobile Insurance Bureau. This application is designed for up to two vehicles and six operators. If these limits are insufficient, attach an additional ACORD 90 MA. Company/Producer Name of the insurance company that will receive the application or name of the producer submitting the application. Use the actual name of the company within the group in which you wish to have the policy issued. Do not use group names. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Binder/Policy Number assigned by the agent, if a binder is used, or the company, if the policy number is known. Effective Date Month, day and year on which the terms and conditions of the policy will commence. Expiration Date Month, day and year on which the terms and conditions will terminate unless renewed. Applicant's Name and Residential Address Full name of the applicant as it should appear on the policy. The first named insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and the additional insured identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address (not a P.O. Box) at which the first named insured is to receive all correspondence. Phone Telephone number at which the applicant may be reached, including area code and extension, if applicable.

Mail Address (if different) Address at which the applicant is to receive mail; this may be a P.O. Box. Direct Bill/Agency Bill Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. Deposit Premium Deposit submitted with the application. COVERAGES Space is provided for two vehicles. Coverages 1-4 are compulsory and must be provided for each vehicle. Coverages 512 are optional. The applicant may choose all, none or any number of these optional coverages. Refer to the Massachusetts Personal Automobile Manual for descriptions of coverages. Est. Total Premium Aggregate dollar amount owed to the company for all vehicles on this policy. VEHICLE INFORMATION Principal Garaging - City or Town and /Zip City or town in which vehicle number one is primarily located. Year Model year of the vehicle. Make Vehicle manufacturer. Model Manufacturer's trade name for the vehicle. Motorcycle CC Number of cubic centimeters of displacement for motorcycles. Vehicle Identification Number Full vehicle identification number appearing on the title certificate or registration. Registration Plate Number Number on the license plate for the vehicle. Date of Purchase Year the applicant acquired the vehicle. Cost New Original cost of the vehicle. Estimated Annual Mileage Total estimated annual mileage for each vehicle. Odometer Reading Current number of miles on the odometer. Air Bag/Passive Seat Belt Answer "Yes" if the vehicle is equipped with an air bag or automatic shoulder harness seat belt. Anti-Theft Device Answer "Yes" if the vehicle is equipped with an anti-theft device. Vehicle Recovery System Answer "Yes" if the vehicle is equipped with a vehicle recovery system. Leased Auto Answer "Yes" if the vehicle is currently provided through a leasing program. Secured Lender/Lessor

Provide complete name and mailing address of the lending institution holding the loan on the vehicle. Date of Final Payment Date on which the vehicle's loan payments will be completed. DRIVER INFORMATION Operator Name Name of each licensed operator (resident or not). Show the applicant as driver #1, even if not an operator. Date of Birth Birth date of each driver and household resident (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44). Driver's License #/Licensed State The complete driver's license number for each licensed operator. Copy directly from license if possible. List the licensed state for each operator. Date First Licensed Month and year in which each operator became licensed. Enter both dates if applicable. Approved Driver Training Answer "Yes" if the operator has completed an approved driver training course. % of Use Indicate how much each vehicle is driven by each operator. Usage for each operator should total to 100%. Driver Information Questions Answer questions A through F with respect to all listed operators. Explain "Yes" responses in the Description of Incident section. Fully describe accidents or convictions, including the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail. Use Remarks section or an additional piece of paper if necessary. Location City and state of the accident or conviction. Date Date of the incident. GENERAL INFORMATION Provide a complete explanation in the Remarks section for any "Yes" responses for questions 1-7. Use additional paper if space in the Remarks section is inadequate. Respond to questions 8-12 in the spaces provided.

Michigan Personal Auto Application ACORD 90 MI (10/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Additional Property Damage Liability coverage in the amount of $500.00 is a basic liability coverage. Personal Injury Protection coverages have been revised to allow for unique Michigan coverages and options. Refer to your state manual. No property damage coverage is available under Uninsured or Underinsured Motorists. Several collision options are shown. Refer to your state manual. The "Good Student" box in the Resident and Driver Information section is deleted, as required by the Michigan Insurance Bureau. Information relating to accidents is limited to the last 5 years, and information relating to coverage cancellation or declination is limited to the last 3 years. Reference to Young Driver Questionnaire, Good Student Certificate and Medical Statement are deleted from the Attachments section. The Fair Credit Reporting Account Statement, Fraud Statement and Applicants Statement on the back of the form have been revised to comply with Michigan law and regulations. The question "How long have you known the applicant?" is deleted, to comply with regulations. Provision is made to allow individuals covered under the policy who are 60 years of age or older, and who have no expectation of actual income loss in the event of an accident, to reject coverage for work loss under Personal Injury Protection coverage. Each individual eligible must sign the application. A statement is added referencing the Michigan Collision Insurance Options Notice (ACORD 62 MI) which must be given to every applicant for auto insurance in Michigan. A statement is added that provides the address and phone number of the Michigan Insurance Bureau. Minnesota Personal Auto Application ACORD 90 MN (1/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage reflects Minnesota's unique coverages. Uninsured and Underinsured Bodily Injury coverage is combined; there is no Property Damage coverage. Comprehensive coverage can include "Full Glass" coverage; refer to your rating manual. Information relating to accidents is limited to the last 5 years, and information relating to suspension or revocation of

drivers licenses is limited to l0 years. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. A statement is added requiring the applicant to acknowledge receipt of a copy of the Minnesota Guaranty Association Notice (ACORD 65 MN). A statement is added requiring the applicant to acknowledge the offering of Uninsured/Underinsured Motorists coverage up to the limits of BI Liability. A statement is added referencing the company's right to cancel coverage during the forty-nine days following the issuance of coverage, for any reason not prohibited by law. The fraud statement on the back of the form is revised to reflect a new Minnesota law. Mississippi Personal Auto Application ACORD 90 MS (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists coverage's are combined. Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists coverage's up to the limits of the policy's Liability limits, and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected. Missouri Personal Auto Application ACORD 90 MO (10/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage does not apply; this is not a "no-fault" state. Uninsured and Underinsured Motorist Property Damage coverage's are not available. A required statement has been added to the back of the form, indicating that the premium quoted is an estimate only, and that premium charged will be in accordance with the company's filed rates. A statement has been added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists coverage. Montana Personal Auto Application ACORD 90 MT (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Uninsured Motorists Property Damage and Underinsured Motorists coverage's are not available. A statement has been added to the back of the form, indicating that a copy of the Privacy Act notice has been given to the applicant. A statement has been added to the back of the form, referencing the offering of Uninsured Motorists coverage up to the limits of Bodily Injury liability coverage. Nebraska Personal Auto Application ACORD 90 NE (8/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Fields are added to the Producer section, to identify "Producer ID" and "Agency ID," as required by Nebraska regulation. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the limits of the policy's Bodily Injury Liability limits and the applicant's right to select lower limits. The fraud statement is removed. It does not apply in Nebraska. Nevada Personal Auto Application ACORD 90 NV (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage's are not available; this is not a "no-fault" state. Underinsured Motorists Bodily Injury coverage is included in Uninsured Motorists Bodily Injury coverage. Uninsured and Underinsured Motorists Property Damage coverage's are not available. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added to the back of the form, referencing the state supplement, ACORD 61 NV, which must be given to the applicant to explain the available options under Medical Payments and Uninsured Motorists coverage. New Hampshire Personal Auto Application ACORD 90 NH (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage's are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. New Jersey Personal Auto Application ACORD 90 NJ (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages have been revised to provide for unique New Jersey coverages. Refer to your State Manual. Uninsured and Underinsured Motorists coverages are combined. Comprehensive is changed to "other than collision coverage". Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. The fraud statement on the back of the form is revised to comply with New Jersey law. A statement has been added referencing the offer of Uninsured/Underinsured Motorists coverage up to the policy's BI limits. A statement has been added referencing the Insurance Inspection Report, ACORD 94. The producer will indicate if a vehicle inspection has been requested or waived, according to individual company procedures. New Mexico Personal Auto Application ACORD 90 NM (11/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage coverages up to the limits of the policy's Liability limits and the applicants right to select lower limits, or

to reject coverage entirely. The applicant must initial the option selected. New York Personal Auto Application ACORD 90 NY (9/2000) Reference to "Registered Owner if different from above" in the Applicants section is deleted. This item is covered by General Information question 1. Reference to "Supplementary Uninsured Motorists Coverage" is revised to "Supplementary Uninsured/Underinsured Motorists Coverage" in the Coverages/Premium section on the front of the form, and in the last statement on the bottom of the back of the form. These changes are required by a recent change in NY law. North Carolina Personal Auto Application ACORD 90 NC (9/2000) Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. A field is added in the Coverages/Premiums section to record information about a new option, "Alternative Economic Loss Coverage." Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agent sthat charge policy fees. Added instruction in the Resident and Driver Information section to show name as it appears on drivers license. A note is added to the Employment Information section requiring that self-employed applicants state the nature of their business. An instruction is added to General Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments). These revisions will be made to all state-specific ACORD 90 forms, but only when other specific changes must be made in the individual states. North Dakota Personal Auto Application ACORD 90 ND (10/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages revised to reflect North Dakota's unique coverages and options. Refer to your State Manual. Uninsured and Underinsured Motorists Bodily Injury coverages are combined; Uninsured/Underinsured Motorists Property Damage coverages are not available. Statement is added to the back of the form to allow the applicant to reject Additional Personal Injury Protection coverage. The applicant must initial the form. Ohio Personal Auto Application 90 OH (4/98) The statement on the back of the form relating to Uninsured Motorists coverage is revised to include reference to UMPD, in addition to UMBI. Oklahoma Personal Auto Application ACORD 90 OK (10/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Underinsured Motorists BI coverage is included in Uninsured Motorists coverage; Property Damage coverage is not available. The fraud statement is revised to comply with Oklahoma law. Oregon Personal Auto Application ACORD 90 OR (2/98) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect Oregon's unique coverages and options. Refer to your State Manual. Underinsured Motorists coverage is included in Uninsured Motorists coverage. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added to the back of the form, referring to the state supplement, ACORD 61 OR, which must be given to the applicant to explain Uninsured Motorists coverage, and the options available. Pennsylvania Personal Auto Application ACORD 90 PA (9/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage sections have been revised in accordance with unique Pennsylvania coverages and options. Refer to your state Manual. Provided for the selection of "stacked" or "non-stacked" coverage under Uninsured and Underinsured Motorists BI coverages. Property Damage coverage is not available. The Fraud Statement is revised to comply with Pennsylvania law. Puerto Rico Personal Auto Application ACORD 90 PR (3/97) Following are the differences from ACORD 90, the generic Personal Auto Application. In the "Vehicle Description/Use" section, reference to "car pool," "odometer reading," "annual mileage," "governing driver" and "anti-lock brakes" were deleted. Reference to vehicle registration and plate number were added. The "Coverages/Premiums" section is revised to reflect only coverages offered in Puerto Rico. In the "Resident and Driver Information" section, reference to driver training and student discounts were deleted. Rhode Island Personal Auto Application ACORD 90 RI (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists coverages are combined. Statements are added to the back of the form that: 1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected; 2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if Uninsured/Underinsured Motorists Bodily Injury coverage is rejected; 3. Allow the applicant to acknowledge the offer of Uninsured/Underinsured Motorists Property Damage coverage, and the options selected. The applicant must initial the options selected.

South Carolina Personal Auto Application ACORD 90 SC (1/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. A box relating to "Facility Code" is added to the front of the form, to provide information relating to the re-insurance facility. Provision is made to record the Fire District (required when Physical Damage coverage is written). Medical Payments coverage is deleted; Medical expenses are included under Personal Injury Protection coverage. A mandatory $200.00 deductible is shown for both Uninsured and Underinsured Motorists Property Damage coverages. South Dakota Personal Auto Application ACORD 90 SD (9/98) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to reflect South Dakota's unique coverages and options. Refer to your state Manual. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form to allow the applicant to select or reject supplemental auto coverage. The applicant must initial the form. Tennessee Personal Auto Application ACORD 90 TN (11/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. A mandatory $200.00 deductible is shown for Uninsured Motorists Property Damage coverage. Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage coverages up to the limits of the policy's Liability limits and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option(s) selected. Texas Personal Auto Application ACORD 90 TX (11/96) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are revised to provide for various Texas coverages and options. Refer to your state Manual. Uninsured and Underinsured Motorists coverages are combined. The Property Damage deductible is $250.00. Comprehensive coverage is replaced by "Other than Collision"; refer to your State Manual for options. Statements are added to the back of the form requiring the applicant to acknowledge the explanation of Uninsured/Underinsured Motorists coverage and Personal Injury Protection, and to acknowledge selection/rejection decisions by initialing the statements. Utah Personal Auto Application ACORD 90 UT (1/2001) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages reflect the unique coverages available in this state. Underinsured Motorists Property Damage coverage is not available. A statement is added to the back of the form explaining arbitration as an alternative to court action. This statement is required by Utah law. A statement is added requiring the insured to initial the selection/rejection of various Uninsured and/or Underinsured Motorists coverage options. ACORD 90 VI (2001/03) Following are the differences specific to the Virgin Islands. Checkboxes are provided to record NEW or RENEWAL in the APPLICANTS section. Personal Injury Protection, Uninsured and Underinsured Motorists coverage fields reflect the territory's unique coverages. Vermont Personal Auto Application ACORD 90 VT (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists coverage. The Fair Credit Reporting Act Statement is replaced with Vermont's Fair Credit law requirements. A statement is added to the back of the form, referencing the explanation of Uninsured Motorists coverage to the applicant, and the applicants selection of coverage. Virginia Personal Auto Application ACORD 90 VA (10/98) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is revised to reflect the coverages and options available in Virginia. Refer to your state Manual. Underinsured Motorists coverage is included in Uninsured Motorists coverage. A required statement is added referring to the Company's right to cancel the policy for any reason within the first 60 days it is in effect, and thereafter for reasons stated in the policy. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. A statement is added referencing the offering of Uninsured Motorists coverage. Dual lines are provided for the initials of more than one named insured at the end of the statement on the back of the form relating to Uninsured Motorists coverage selection. A recent court decision determined that each named insured must acknowledge the offer of UM coverage. Washington Personal Auto Application ACORD 90 WA (8/2000) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage is revised to reflect Washington's unique coverages and options. Refer to your state Manual. Added "Auto Loan" coverage in the coverages/Premium section. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added to the back of the form referring to the options available under Underinsured Motorists and Personal Injury Protection coverages and the applicant's right to reject these coverages.

West Virginia Personal Auto Application ACORD 90 WV (11/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the state supplements, ACORD 60 WV, 61 WV, and 62 WV, with respect to the offering and selection of Uninsured and Underinsured Motorists coverages. Wisconsin Personal Auto Application ACORD 90 WI (7/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statements added to the back of the form: 1. Acknowledging the offer of Medical Payments coverage, and allowing the applicant to reject this coverage; the applicant must initial the form of coverage that is rejected. 2. Acknowledging the offer of Uninsured and Underinsured Motorists Bodily Injury coverages, and the options available. Wyoming Personal Auto Application ACORD 90 WY (1/97) Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection is not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverage is not available. A statement is added to the back of the form referencing the offering of Uninsured and Underinsured Motorists coverage.

Personal Inland Marine Application 81 (4/2001)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide provides assistance in completing the ACORD Personal Inland Marine Application. This form can be used as a stand-alone application. It can also be used as a supplement to the Homeowners Application (ACORD 80) if scheduled personal property is being submitted as part of a homeowners transaction. The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Sections of the Forms Instruction Guide. On the ACORD website (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS. APPLICANT INFORMATION Age First named applicant's age at time of application. Marital Status Marital status of the first named applicant. Examples: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . .Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Occupation/Spouse's Occupation A brief text description of the occupation of the applicant(s) named in the top identification section. Terr Code Location of the dwelling based on individual state bureau or company homeowner,s manual pages. Protect Class Dwelling,s four-character fire protection grade found in individual state homeowner,s manuals. Fire District/Code Number Dwelling's fire district name and corresponding five-character code number found in individual state homeowner,s manuals, Location of Property Indicate the physical address of the property to be insured only if it is different from the mailing address.

Dwelling Type(s) Indicate each residence type. Possible options are: · Dwelling, up to four family building · Townhouse · Rowhouse · Apartment · Condominium · Co-operative. Construction Type(s) Primary type of building material used to construct the dwelling. # Families Number of families in each listed location. Other List any other information that may be required by or helpful to the company receiving this application. COVERAGES Enter the amounts of insurance, the rate (carried to three decimal places), and premium (rounded to the nearest whole dollar) for each applicable coverage. If objects are stored at different locations, include information for each additional location. Jewelry Total amount for all jewelry. Furs Total amount for all furs. If more than one category of furs is to be covered, use the blank space provided (Nos. 10-14). Fine Arts Total amount for all fine arts. Include paintings, pictures, etchings, sculptures or other objects of art. Note general information question 2. Cameras Includes photographic equipment and supplies; note general information question 5. Musical Instruments Includes musical instruments, instrument cases, sound and amplifying equipment; note general information question 5. Silverware Includes flatware and other silverware and goldware. Stamps and Coins Stamps and coins may either be scheduled individually or blanket coverage may be provided. Check the box below No. 7 if unattended car coverage is to be included. Golfer's Equipment Total amount for golfer's equipment. Personal Computers Total amount for personal computers. Unattended Car Coverage (Stamps and Coins) Additional rating information may be required for this coverage. Check with your company. Broad Form Pair and Set Coverage Additional rating information may be required for this coverage. Check with your company. Non-Mobile Organ Coverage Additional rating information may be required for this coverage. Check with your company. Safe Credit Identify any property stored in a safe. If a bank vault is used, provide the name and address of the bank. Breakage Coverage Use an asterisk (*) to identify each item on the Schedule of Property that has breakage coverage. ACV Loss Settlement/Replacement Cost Loss Settlement

Indicate if either of these options apply. Blanket Coverage If coverage is to be written blanket, check the box and attach a statement of values. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. 1. Any protective devices/systems in use? Provide the details for the system; include the type of system, whether it is local, central, or directly connected to a central station, and whether it was professionally installed. For scheduled jewelry kept at home, a copy of the alarm specifications sheet must be submitted to qualify for a credit. 2. Will any property be exhibited? This question refers to exhibition away from the insured's premises. Provide information regarding exhibition of the property. Include what type of property, the location where the property will be exhibited, type of exhibition, type of security, or security devices that may be used, and the duration of the exhibition. 3. Will any special restriction/endorsements apply? List the endorsements and/or describe the restrictions. If the endorsements/restrictions do not apply to all property classes or items, designate the classes or items to which they apply. 4. Will any type of deductible apply? Provide the amount and type of deductible. Designate which classes or items should have the deductible applied. 5. Is any property used professionally/commercially? List those items used in this capacity. Also, provide an explanation of how the property is used. Include cameras and musical instruments. 6. Any other insurance with this company? Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. If other insurance is in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal. 7. Did any loss occur during the last 3 years? Describe in detail all losses during the last three years; use the Remarks section. Include data on the applicant, the type of loss, the amount of the loss, the date and the disposition. 8. Any coverage declined/canceled/non renewed? If this situation occurred, provide the circumstances under which it happened. This question may not be asked in Missouri. Prior Insurance & Policy Number Provide the prior insurance company's name and the complete policy number including any prefix or suffix. SCHEDULE OF PROPERTY List those items that are to be covered on the policy in this section. Designate which items should receive additional coverage or rating consideration. Since a total value for each property class must be provided, group together all items of the same property class and with the same rating characteristics. When working with a long list of items, you may attach a list of the items rather than completing this section of the application. When listing items, provide a full description including serial numbers, if applicable. Appraisals or sales receipts must be included where required.

Vehicle Form

This form stores your client's vehicles. Each record contains complete information about a vehicle. You can use it to add, edit, or delete vehicle records. The vehicle information can be used to automatically fill certain forms (Automobile Loss Notice 2, Business Auto Section 127, Personal Automobile Application 90, Personal Auto Policy Change Request 71, Insurance Identification Card 50, Personal Umbrella Application 83, Commercial Policy Change Request 175, and the Vehicle Schedule 129). Automobile Loss Notice 2 The Automobile Loss Notice has a section for one automobile. If you would like to automatically fill the the section, click the Add / Edit Vehicle button. A list of vehicles that you have assigned to your client appears. Single-click the vehicle that

you would like to add to the form and click OK. Selected fields on the form will be filled with information from the vehicle record. Business Auto Section 127 Page 2 of Business Auto Section has sections for 8 automobiles. If you would like to automatically fill the Page 2, click Add / Edit Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you would like to add to the form and click OK. The form will be filled with vehicles in the order they were selected in the grid. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. Personal Automobile Application 90 If you would like to automatically fill the Vehicle Description / Use section of the Personal Auto App, click Add / Edit Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you want to add click OK; you can add up to 4 vehicles. Several fields from the Vehicles form transfers over to the app. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. Personal Auto Policy Change Request 71 This form has a section for three automobiles. If you would like to automatically fill the the section, click the Add / Edit Vehicle button. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you want to add click OK. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. Selected fields on the form will be filled with information from the vehicle records. Personal Policy Change Request 175 This form has a section for 2 automobiles. If you would like to automatically fill the the section, click the Add / Edit Vehicle button. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and singleclick each vehicle that you want to add click OK. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. Selected fields on the form will be filled with information from the vehicle records. Personal Umbrella Application 83 Page 1 of Personal Umbrella Application has sections for 6 automobiles. Three automobiles and three recreation vehicles. If you would like to automatically fill the Page 1, click Add / Edit Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you would like to add to the form and click OK. The form will be filled with vehicles in the order they were selected in the grid. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. Insurance Identification Card 50 If you would like to automatically fill Insurance Identification Cards, click Add / Edit Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that needs a form and click OK. Each vehicle that was selected creates a new Insurance Identification Card record. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. If you wish to create multiple ID Cards using the Vehicle form but wish to avoid retyping information such as State Title, State, Policy Number, Effective Date, Expiration Date, and client information, you can create a new record and fill in the information one time. Next, click the Add / Edit Vehicles button, highlight all the vehicles that you wish to create ID Cards for, and click OK. Vehicle Schedule 129 This form has sections for 7 vehicles. If you would like to automatically fill these sections, click Add / Edit Drivers. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you want to add click OK. Fields from the Vehicles form transfers over to the form. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid. ENTRY HELP Veh # Number assigned by the agent to this vehicle for purposes of tracking in the application process. Year Vehicle's model year. Make Vehicle's manufacturer (e.g., Buick). Model Manufacturer's model name (e.g., Regal). Body Type Vehicle's body type (e.g., 4 door sedan). Vehicle Type Check the appropriate box. PP (private passenger), SPEC (special), or COML (commercial). V.I.N. Full vehicle identification number assigned by the manufacturer. City, State, Zip where garaged

List the location where this vehicle is normally garaged. Terr Enter the rating territory in which the vehicle is principally garaged. GVW/GCW These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly. GVW Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer. GCW Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which the truck-tractor is designed as specified by the manufacturer. Class This is the primary industry classification code found in rating manuals for commercial vehicles as determined by: If this is a fleet or non-fleet policy Commercial autos by size, business use, radius of operation and whether truck or trailer type Public autos by type of vehicle, radius or seating capacity S.I.C. This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. Factor This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you are not rating this application. Seating Capacity Used for public vehicles and livery vehicles. Enter the number of passenger seats available. Sym/Age Enter the age of the vehicle in years, as follows: 1 = Current model year 2 = First preceding model year 3 = Second preceding model year 4 = Third preceding model year 5 = Fourth preceding model year 6 = All other autos Cost New If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and equipment. Radius Enter the appropriate radius code as follows: L Local Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging. I Intermediate Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging. LD Long Distance Regularly and frequently operated beyond a radius of 200 miles. Farthest Term For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of this vehicle, that this vehicle travels to. Drive to Work/School If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are: Drive to Work or School under 15 miles one way Drive to Work or School 15 miles or over one way Use Check the appropriate box for the primary use of this vehicle. Options are: Pleasure ¾ Private passenger vehicles or pickups/vans not used for business purposes Farm ¾ Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch Retail ¾ Pick up or delivery of property to individual households Service ¾ Transportation of personnel, tools, equipment or supplies to or from a job site Commercial ¾ The transportation of property in vehicles other than those defined as retail or service

Check Coverages Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the symbols indicated in the coverage section of ACORD 137. Abbreviations are: Liab ¾ Liability PIP ¾ Personal Injury Protection ("No Fault" coverage) Add'l PIP ¾ Additional Personal Injury Protection Med Pay ¾ Medical Payments Unins. Mot ¾ Uninsured Motorist Underins Mot ¾ Underinsured Motorist Towing & Labor ¾ Towing and Labor Spec C of L ¾ Specified Cause of Loss F ¾ Specified Cause of Loss by Fire F & T ¾ Specified Causes of Loss by Fire and Theft F ,T, & W ¾ Specified Causes of Loss by Fire, Theft and Windstorm LSP ¾ Limited Specified Perils Comp. ¾ Comprehensive Coverage Coll. ¾ Collision Coverage Deductibles Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt ¾ Stated Amount basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the collision deductible in the space provided.

Personal Umbrella Application 83 (7/2001)

Personal Umbrella or Personal Excess insurance policies are personal lines insurance contracts that provide for indemnification of third parties as a result of damages and/or injuries sustained due to the insured's negligence with respect to personal acts. Coverage for negligence arising out of any professional activities and nearly all business pursuits conducted by the insured is normally excluded. It is important to note that personal umbrellas normally provide personal injury in addition to bodily injury coverage. While the latter coverage deals solely with physical injuries, the former includes "injuries" sustained as a result of libel, slander, defamation of character, false arrest and other "non-physical" perils. Personal umbrellas typically operate in excess of or "overlay" the primary liability coverage contained in other personal lines insurance contracts such as private passenger auto, homeowners and watercraft. Coverage limits are written on a combined single limit (CSL) basis. In some cases, Personal umbrellas may provide basic or "first dollar" coverage for certain types of negligence for which there is no primary coverage. Personal umbrellas can also overlay coverages afforded under certain commercial insurance contracts such as owners, landlords and tenants liability policies. They also provide that the insurer will pay legal defense costs on a first-dollar basis in addition to the policy limits. The majority of personal umbrellas contain a provision for a retained limit which effectively operates as a per occurrence deductible. Although insurance coverage afforded by a personal umbrella is typically operative "worldwide" and specific units at risk (such as automobiles) may be related to locations in varying geographical locations (rotary territories), premiums are developed on the basis of unique personal umbrella rates applicable at the insured's primary residence. No known requirement for allocating premiums back to other exposure locations exists. The underwriting process for any personal lines policy begins with the submission of a completed application. The generic sections of each personal lines form are explained in the Personal Lines Generic section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website, (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS. UMBRELLA INFORMATION Policy Amount Limit of liability. Retention The amount of liability retained by the insured. Retention is generally expressed in whole dollars but can be a percentage.

Optional Coverages to Apply Insurance companies often provide options or special coverages. Examples: · Professional · Business · Major medical · Uninsured/underinsured motorists Specifically note each option desired and provide all the information necessary for underwriter review and policy issuance. In Florida, Indiana, Louisiana, Ohio, Vermont and West Virginia, Uninsured Motorists coverages must be offered in umbrella policies up to the liability limit of the policy when auto liability coverage is included. In Florida, auto supplement ACORD 61 FL should be used with umbrella policies. Refer to the instructions for use of this form in the State Forms section of this guide. In the other states mentioned above, no supplement is required, but the insured must initial the appropriate statement at the bottom of the back of this form, indicating selection or rejection of UM coverage. Premiums Methods for calculating the policy premiums differ by company, but usually include a basic amount. Any additional autos, residences, watercraft or special options involve additional premiums based on an established schedule. Calculations The insurance company may require use of specific multipliers or factors which can be shown here. PAYMENT PLAN Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan for payment. PRIMARY POLICY INFORMATION Type of Policy The most common coverages are pre-printed on the application. Space for additional primary policies in force is provided. Company/Policy Number Provide the name of the insurance company and the full policy number including any alphabetical prefix and/or suffix. Be sure to list all primary policies for all insureds in the household such as children with their own auto policies. Policy Period Effective and expiration dates for each primary policy in force. Limits of Liability Limits for each policy. Some policies may offer different limits for specific hazards (fire, legal liability or waterskiing) which must be identified. Use the blank spaces to provide this information. REAL ESTATE Location Address of all owned, leased, rented or occupied residences, buildings, farms and vacant land. Description Differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. Interest Show the interest of the applicant (owner, lessor, lessee, occupier, etc.) for each described location. Yr Built Year the dwelling was built, use four digits (e.g., 1952). Occupancy Identify the occupants of the premises (self, self and tenant, tenant, three families, doctor's office). Indicate if the occupancy is seasonal. AUTOMOBILES Year and Make and Model List all automobiles owned, leased or furnished for regular use. RECREATIONAL VEHICLES Year and Type, Make and Model

Provide the same information as for automobiles; be specific regarding the type of vehicle. Specify if it is a dirt bike, van, scooter, etc. Include size of engine in cubic centimeter displacement and/or horsepower. WATERCRAFT Year Model year of the unit in YYYY format. If built at home, the year built. Motor Type, Manufacturer and Model Indicate type of motor (inboard, outboard, etc.), manufacturer and model. Length Overall length measured in feet from bow to stern. Horsepower Total horsepower of the watercraft. Max Speed Enter the maximum speed of the craft. State if measured in knots or miles per hour. Value Companies may require either one or both dollar amounts. Indicate in the corresponding box whether cost new or current value applies. If two amounts are required, enter the cost new first. Waters Navigated Body of water or geographical area navigated (e.g., Atlantic, Great Lakes, Inland Waterways, Pacific, Rivers). Specific names (Hudson River, San Francisco Bay) can also be provided. OPERATOR INFORMATION Name Names of all household members and all operators of vehicles or watercraft, even if they are not members of the household. The listing should include children at home or relatives/friends who may use a vehicle or watercraft. Sex/Mar Stat Sex and marital status of each driver and household member.. Date of Birth Date of birth of each driver and household resident (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44.) Drivers License #/Licensed State Complete drivers license number and license state for each licensed operator. Copy directly from license if possible. Social Security # Social security number for each driver. Vehicle, % Use The vehicle operated by each of those named above, the percentage of use of the vehicle attributed to that operator, and annual mileage or any other information required by the insurance company. Craft, % Use The watercraft operated by each of those named above, the percentage of use of the craft attributed to that operator, and annual mileage or any other information required by the insurance company. EMPLOYMENT Occupation Some job titles are not very specific (Manager, Analyst). Expand upon the title as necessary (e.g., Department Manager of Plastics Manufacturer). Employer's Name and Address Name of the employer and the address of the location where employed. Yrs Empl Number of years the applicant(s) has been with the employer indicated above. If less than 3 years, provide the number of years in the same or other career field or industry in the Remarks area. PRIOR EXPERIENCE

Losses Follow the company guidelines for required information on prior losses. Prior Carrier and Policy Number Provide the prior insurance company's name and the complete policy number, including prefix and suffix. GENERAL INFORMATION Use the Remarks section to provide additional information for any of the questions below answered with a "Yes" response. 1. Any aircraft owned, leased, chartered or furnished for regular use? This does not include scheduled commercial airlines. If the applicant is a licensed pilot, the company may require additional information. 2. Any operators convicted for any traffic violations? Provide the name of driver involved, the date and nature of the violation and/or conviction. 3. Any operator have physical /mental impairment? Provide the name of the driver and the details. Determine if the operator's impairment (e.g., amputation or epilepsy) could hinder the safe operation of a vehicle. Provide a description of any special equipment installed and treatment or medication being administered. 4. Any swimming pool on premises? If there is a swimming pool on any covered premises, indicate whether the pool is above/in ground and whether there is an approved fence. 5. Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes? Describe all commercial or business use. 6. Any real estate, vehicles watercraft, aircraft owned, hired, leased or regularily used, not covered by primary policies? If yes, explain why no primary coverage exists. 7. Do you engage in farming operation? Describe all farming operations performed by the applicant including custom farming. Include size of the farm, its acreage and annual sales. 8. Do you hold any non-compensated positions? List any unsalaried or other philanthropic position the insured holds. Examples: · Corporation's board of directors · Master of a lodge · Commodore of yacht club 9. Any full-time employees? If the applicant employs any full or part time employees, provide information on whether they work inside or outside, number of employees, duties, number of hours worked per week and total payroll (e.g., housekeeper, gardener). 10. Any non-owned property exceeding $1,000 in value in your custody? If the applicant is responsible for the property of others, list the type of property. Examples: · Firearms · Art · Computers 11. Any business and/or professional activities included in primary policies? Provide the nature of such professional or commercial activities and whether or not income is produced. 12. Any primary policy have reduced limits of liability? Include any primary policy endorsed to limit, restrict, exclude or otherwise modify coverage provided by the basic policy form (e.g., liability may be reduced when the applicant is using watercraft for waterskiing, or for a youthful operator when operating a motor vehicle). 13. Any coverage declined, cancelled, non-renewed? If any policy had this action taken, provide the reasons and circumstances. This question cannot be asked in Missouri. 14. Does applicant or tenants have any animals or exotic pets? Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others or to other animals.

15. Has insurance been transferred within agency? Indicate if prior carrier information shown on the front of the application represents a policy being transferred within the agency. Give reason for transfer. 16. Any pending litigation, court proceedings or judgement? If yes, describe in detail.

Policy Certification Log 26 (9/93)

Use the Policy Certification Log (ACORD 26) with the Certificate of Property Insurance (ACORD 24), the Certificates of Liability Insurance (ACORD 25-N & 25-S) and the Evidence of Property Insurance (ACORD 27). Its purpose is to keep a manual record or to prepare a hard copy of a computer record of all certifications issued for a single insured. The form summarizes the information contained in the above forms and identifies several key items to check when issuing renewals. IDENTIFICATION SECTION Producer Producer's name and address. Insured Name and mailing address of the insured as found on the declarations page of the policy. Companies Affording Coverage Names of the companies affording coverage to the insured for which a Certificate of Insurance or Evidence of Property Insurance form has been issued. Policy Period Effective and expiration dates for the referenced policies. CERTIFICATES/EVIDENCE Certificate/Evidence Holder ACORD 25-S and ACORD 27. Mailing Address Mailing address for the corresponding certificate holder(s) or additional interest(s). Line of Business Enter appropriate abbreviations for the coverages indicated on the Certificate of Insurance or Evidence of Property Insurance. Examples: WC = Workers Compensation GL = General Liability Auto = Automobile HO = Homeowner Co Ltr Company Letter from the Companies Affording Coverage Section for the company providing the corresponding coverage. Sched Auto Check this box if the Certificate of Insurance or Evidence of Property Insurance was issued for a specific auto that is scheduled on a policy. Word Change Indicate if the wording that appears on the Certificate of Insurance or Evidence of Property Insurance has been changed. Add Ins If the Certificate/Evidence Holder has been added to the policy as an Additional Insured, mark "X " in this field. Perm Indicate if a new Certificate/Evidence is to be issued annually. Date Issued Month/day/year the Certificate/Evidence was issued. # Days Canc Indicate the number of days given within the Cancellation portion of the Certificate of Insurance or Evidence of Property Insurance. Month/Year Certification Expires Month and year the certification expires.

Property Loss Notice 1 (2/2001)

Use the ACORD Property Loss Notice (ACORD 1) for reporting commercial and personal lines property losses including Homeowners, Dwelling Fire, Inland Marine, Commercial Property, Flood, Wind and others. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name and address. Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Miscellaneous Info Use this field for large accounts to list site and location codes or to enter the claim number on a phone-in report. Date & Time of Loss Date and approximate time that the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g., 01/11/94 12:15 A.M.). Previously Reported Indicate if this is the first report on the loss that has been given to the company; whether written or by telephone. If not, list in the Remarks section when other report(s) have been made. Policy Type Complete the company name and policy number for the types of policies written. Do not repeat the property/homeowners company name and policy number unless flood and/or wind coverages are written on separate policies. Property/Home For commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies. Flood For monoline flood policies. Wind For monoline wind/hail policies. Company Name of the applicable insurance company and the company's NAIC number. Use the actual name of the company within the group to which you are sending the loss notice. Do not use group names. Policy Number Number assigned by the insurance company for the policy. Effective Date Date on which the terms and conditions of the policy commenced. Expiration Date Date on which the terms and conditions of the policy will or have expire(d). INSURED Name and Address of Insured and Spouse Name and mailing address of the insured and spouse (if applicable) as found on the declarations page of the policy. Date of Birth, Soc. Sec. # or FEIN

Date of birth and social security number or Federal Employer Identification Number for both the insured and spouse (if applicable). Residence Phone For an individual, the home telephone number, including area code of the insured. Business Phone Business telephone number, including area code and extension of the insured. CONTACT Contact Insured If the individual to contact for information is the same as the named insured, check this box and leave blank the areas for contact name, address and phone numbers. Person to Contact Name and address of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked. Residence Phone Enter the home phone number, including area code, of the contact named above. If it is the insured, leave this field blank. Business Phone Business telephone number, including area code and extension of the contact. If it is the insured, leave this field blank. Where to Contact Indicate where this person should be contacted (e.g., home, office, hospital). When to Contact Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). LOSS Location of Loss Give the physical location of the loss. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured's home or Loc 3, Bld 2; 151 Main St). Police or Fire Dept. to Which Reported Name of the municipal or county police or fire department to which the loss was reported, including the precinct or station number if available. Kind of Loss Indicate the type of loss. Check any appropriate box that may apply to the type of loss. If the loss is different from the preprinted options, check the "other" option and list the loss type in the available space. Probable Amount Entire Loss Estimate the dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as "small" or "substantial". Description of Loss & Damage Briefly describe the cause of the loss and resulting damage, including the areas of buildings which were damaged. Note: If the loss resulted in bodily injury to individuals or damage to the property of others, indicate in the Remarks Section and complete the appropriate additional claim form. POLICY INFORMATION Mortgagee Name and address of all mortgagees on the property that incurred the loss. If there is more than one, use the Remarks Section if necessary. If there is no mortgagee, check the appropriate box. HOMEOWNER POLICIES SECTION 1 ONLY Use this section for Homeowner and Dwelling Fire policies only. For Homeowner, it is limited to the property coverages of section 1. Use ACORD 3 for reporting liability losses. Coverage A Dwelling Coverage amount provided for the dwelling on the policy. If wind coverage is excluded, check the box below. Coverage B Other Structures Coverage amount provided for appurtenant private structures on the policy.

Coverage C Personal Property Coverage amount provided for unscheduled personal property on the policy. Coverage D Loss of Use Coverage amount provided for loss of use/additional living expenses on the policy. Deductibles Indicate any deductibles that apply to the policy. Describe Additional Coverages Provided Describe and give amount for any additional property-related coverages on the policy. Subject to Forms Enter all attached policy form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe the endorsement. FIRE, ALLIED LINES AND MULTI-PERIL POLICIES This section outlines the coverages written on commercial lines policies. Item Building number or Inland Marine item number for this subject of insurance. Subject of Insurance Indicate whether the corresponding "amount" applies to the coverage of building, contents/personal property, or some other subject of insurance by marking X in the appropriate box. For other than building or contents subjects of insurance, list the subject's name in the available space next to the option box. Examples of other subjects of insurance include business interruption and combined building and contents. Amount Dollar amount of insurance provided on the policy for this subject of insurance. % Coins Percent of coinsurance that applies to this subject of insurance. Deductible Indicate the deductibles that apply to this subject of insurance. Coverage and/or Description of Property Insured Describe the coverages written for this subject of insurance and briefly describe the property insured. Subject to Forms Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe the endorsement. FLOOD POLICY This section outlines the coverages issued on a separate flood policy. Building/Contents Appropriate building and contents policy limits. Deductible Deductible amounts for the building and contents parts of the policy. Zone Flood rating zone. Pre Firm/Post Firm Check whether the policy was issued based on a Flood Insurance Rate Map (Post Firm) or prior to a map being released (Pre Firm). Diff in Elev Difference in Elevation - Indicate the approximate distance above or below sea level. Form Type Indicate whether the flood policy is issued on a general, dwelling or condominium form. WIND POLICY This section outlines the coverages issued on a separate wind policy.

Building Building policy limits. Deductible Deductible for the building limit. Contents Contents policy limit. Zone Wind rating zone if appropriate. Form Type Indicate whether the wind policy is issued on a general, dwelling or condominium form. REMARKS/OTHER INSURANCE Explain any other property insurance in force at the time of loss. Include company, policy number, coverages and amount of coverages. Provide any other information that will assist in properly reporting and settling this claim. (For New York only, provide the previous address of the insured, and the wife's maiden name, if applicable.) CAT # If a catastrophe number has been assigned by the Property Claim Service or other industry organization, enter it here. This is the number assigned to the event which caused the claim being described. FICO # If a flood number has been assigned by the Flood Insurance Coordinating Office, enter it here. This is the number assigned to the flood that caused the claim being described. Adjuster Assigned If known, enter the name and telephone number, including area code and extension, of the adjuster assigned to this loss. Adjuster # Control number assigned to the adjuster. Date Assigned Date the adjuster was assigned to this loss. Reported by Indicate the name of the individual who reported the loss. Reported to Indicate the name of the individual within the agency or company to whom this loss was reported. Signatures of Producer and Insured This form should be signed by the producer and the insured. Note: Important state information is on the second side of this form.

Property Section 140 (8/2001)

This guide provides the user with basic instructions for completing the ACORD Property Section Application. The Property Section has been designed to handle the basic underwriting and rating needs for commercial property exposures. The Property Section accommodates two locations, with coverage and rating information recorded separately for each location. This form was designed to be used in conjunction with the CommercialInsurance Application - Applicant Information Section (ACORD 125). Please turn to the chapter on the ACORD 125 for information on that form. IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address fax and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Enter the Effective date on which the terms and conditions of the policy will commence. Expiration Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Use this field to indicate the audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other PREMISES INFORMATION Complete the front of the form for a single building on a premises, and the back of the form for a second building or a second premises. Use additional forms for additional buildings or premises. Premises # Enter the premises location number as it appears on the ACORD 125 Premises Information Section. Building # Enter the building number(s) associated with this location. Street Address Enter the street address as shown on ACORD 125. Subject of Insurance Enter all units at risk/coverages that are to be insured at this particular location

number/building number combination. Examples: · Building · Personal Property · Extra Expense · Business Income Amount Enter the amount of insurance required for the corresponding subject of insurance. Coins % The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage. Valuation Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . . Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value Causes of Loss Enter the causes of loss the subject of insurance is to be covered for. Examples: · Basic · Broad · Special excluding theft · Earthquake Inflation Guard % The inflation guard percentage gives an automatic increase in the amount of coverage based on a percentage over time. List both the percentage amount and the period of time during which it applies (e.g., 4% per year). Deductible Enter the deductible amount that is to apply to this subject of insurance. Blkt Cov Check this column for each subject of inusrance that is to be included in thecalculation of an average blanket rate. Forms and Conditions to Apply Enter all form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. Additional Information - Business Income/Extra Expense Enter information relating to Business Income and/or Extra Expense coverage that is not provided above. Check the appropriate box for Business Income/Extra Expense, Business Income without Extra Expense, or Extra Expense alone. Type of Business Check the appropriate box depending on the insured's type of business (e.g., non-manufacturing, manufacturing or mining). % Coins Enter the coinsurance percentage. Ord Pay If Ordinary Payroll Exclusion option is selected, check the appropriate box to indicate either the number of days or the dollar amount of ordinary payroll that is to be excluded. If no payroll is to be excluded, show "none" for Ordinary payroll. Power/Heat If a Power, Heat and Refrigeration deduction is to apply, check the box and show the dollar amount of the deduction. Elec Media

If the period of coverage for electronic media and records is to be extended, check the box and show the number of days of extension. Ord or Law If the Ordinance or Law coverage option is to be provided, check the box and show the number of days applicable. Ext Period If the Extended Period of Indemnity option is to apply, check the box and indicate the number of days selected, and, if applicable, the monthly period of indemnity limit, and the maximum period of indemnity limit. Tuition Fees If this coverage applies, check the box and show the dollar amount applicable to coverage for student's tuition fees, and the dollar amount applicable to coverage for other educational services or income. Off Prem Power If the Off Premises Power option applies, check the box and indicate if coverage relates to power, water and/or communications utilities. Describe the utilities and show their addresses in the space provided. Depend Prop If coverage for Dependent Property applies, check the box and indicate the applicable coinsurance percentage. This percentage may be different from the percentage applicable to basic Business Income coverage. Also check the box(es) to indicate if coverage applies to Contributing Locations, Recipient Locations, Manufacturing Locations and/or Leader Locations. Refer to the ISO Commercial Lines Manual for definitions of these terms. Describe the dependent property locations and show their addresses in the space provided. Extra Exp If Extra Expense coverage applies, check the box and indicate the period of restoration, in days, selected. If the Limit on Loss Payment option is to apply, show the percentage limitations selected. Additional Coverages, Options, Restrictions, Endorsements, Rating Information Use this space to enter information on any endorsements or options not provided for above. Also provide rating information required for these options, or by individual company programs. Provide any other coverage information that pertains to this location such as: · Class Rate · Rate Reference · Sales · Earnings Construction Type Enter the construction of the premises. Common construction classifications are: · Frame · Joisted Masonry · Non-Combustible · Masonry Non-Combustible · Modified Fire Resistive · Fire Resistive Distance to Hydrant Distance (in ft.) from the nearest hydrant that supports the protection class used. Distance to Fire Station Distance in miles from the nearest fire station that supports the protection class used. Fire District/Code Number The property's fire district name and corresponding code number which can be found in the individual states manual pages. Prot Cl Enter the fire rating protection class for this location.

# Stories Not including any basement, enter the number of stories for this building. # Basm'ts Enter the number of basements. Yr Built Enter the year in which the building was first constructed. Total Area The number of square feet of the building or area occupied at this location for which insurance is being requested. Building Improvements Indicate if any building improvements have been made since the original construction. Check all applicable improvements, and list the year the improvement was made after the improvement name. Bldg Code Grade Enter the ISO Building Code Grade, if applicable. Tax Code Enter the city, county or state tax code, if required. Roof Type Enter the material used to construct the roof. Examples: · Composition (fiberglass, asphalt, etc.) · Metal · Poured · Slate · Tile · Wood Shake/Shingle Wind Class Check the applicable box. Other Occupancies List any other occupancies located in the building not operated by the insured and not listed in the Description of Operations section on the ACORD 125. If no other occupancy, enter None. HEATING BOILER If there is a heating boiler on the premises, indicate if insurance is placed elsewhere. Right/Left/Rear Exposure and Distance Describe the buildings, structures, activities conducted, or use of property adjacent to the insured premises and provide the distance from the insured premises. Burglar Alarm Type Describe any burglar alarm protecting the building or contents. Descriptive terms such as safe, premises, perimeter, or ultrasonic may be suitable. Certificate Number Enter the Underwriters Laboratories or other testing organization Certificate Number, if applicable. Attach a copy of the certificate to the application. Expiration Date Enter the expiration date of the Certificate. Extent Specify the designated extent of protection as described in the ISO crime rating manual. Grade Enter the alarm grade as described in the ISO crime rating manual (e.g., AA, A, B, C). Central Station/With Key Check all alarm options that apply: Central Station The burglar alarm rings at an alarm company or police department.

With Keys The alarm company, located off the insured's premises, has keys to the applicant's property. Burglar Alarm Installed and Service by Enter the name of the alarm company. # Guards/Watchmen Enter the number of guards and or watchmen employed or contracted for by the insured. Clock Hourly Place an "X" in the box to indicate whether the guard/watchman is required to make hourly rounds using a special time recording device or in connection with the central station service. If other than hourly, indicate the time interval in the Other box. Premises Fire Protection If the premises is sprinklered, indicate the percentage of the area covered by the system, whether wet/dry system, if valve monitors are included and if connected to central station. Cooking facilities, or other special hazards, are often protected by automatic carbon dioxide or chemical systems or other similar devices. Provide a description. Indicate if the risk qualifies as a HPR (Highly Protected Risk). Other devices would include smoke detectors. Fire Alarm Manufacturer Enter the name of the firm, and if it is UL listed. Central Station/Local Gong Check all fire alarm options that apply: Central Station The fire alarm rings at an alarm company, police department or fire department. Local Gong The fire alarm rings on an audible gong located outside of the building. ADDITIONAL INTEREST This section should be used to collect information on any additional interest. Interest Check the appropriate box to indicate if the additional interest in the property is a loss payee or a mortgagee. Rank If there is more than one additional interest, indicate who is first mortgagee, second mortgagee, etc. Name and Address List the additional interests' name and address. Evidence Indicate if a Certificate of Property Insurance or an Evidence of Property Insurance is required. VALUE REPORTING INFORMATION This section contains information for Reporting Forms. It can also be used to enter policy amounts for business personal property at locations other than those designated in the Policy Declarations. Subject of Insurance Enter the subjects of insurance that are to be covered on a reporting form basis. Premise 1, 2 If a reporting form is to be used, provide the average values for each premises location for the prior twelve months. Any Other Location Declared at Inception Enter the amount and provide a list of the locations as required. (Available only with multiple location average rating.)

Any Other Locations Acquired After Inception Enter the amount of insurance desired. Companies will require that you report new locations in accordance with policy terms. These locations usually must be reported within 30 days after the end of the month. If not, coverage reverts back to its level at end of previous report. This may create coinsurance problems. Premises Not Owned or Acquired Limit If the policy provides coverage for business personal property at locations not owned, leased or operated by the insured, enter the premises location limit and aggregate amounts. Also referred to as Incidental Locations. REMARKS Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.

Small Commercial Acct. Pkg. App 165 (11/2000)

The Small Commercial Account Package Application is a stand-alone application designed to collect a variety of rating and underwriting information for smaller commercial packages. This application collects information for Property, Inland Marine, Crime, General Liability, Workers Compensation, Automobile and Umbrella coverages. Agents should check with their carriers to verify any special limitations applicable when using this application. Complex risks should be requested using the full commercial lines application series. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Companies Name of the applicable insurance company and its NAIC code. Do not use group names, but use the actual name of the company within the group in which you wish to have the policy issued. Policies or Program Requested Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company where the line of business will be placed. Proposed Eff. Date Enter the Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Status of Submission Indicate whether the company's response to this application is expected to be a quote or an issued policy. If the risk is bound, so indicate and include the date coverage began and attach a copy of the binder. If more than one option applies, check off multiple boxes. APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) Enter the full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as "et al" or "As their interests may appear" is not acceptable as the name of the insured.

These phrases are not legal entities. Mailing Address (including Zip Code) Address at which the First Named Insured is to receive all correspondence regarding their insurance. Form of Business Organization Identify the applicant as an Individual, Partnership, Corporation, Limited Corporation, Joint Venture or Other. If other, provide a description such as Professional Association. If there is more than one Named Insured, provide the form of business organization for each. In the Remarks section list each Named Insured along with its form of organization. (e.g.: The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.) SIC Code Enter the Standard Industry Classification code applicable to the business of the applicant. Contact for Inspection (Name/Phone #) Name and phone number of the person the carrier is to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. Yrs. In Busin. Number of years the applicant has been in business. This is important. It helps the underwriter determine the expertise and business success of the applicant. PRIOR POLICY(IES)/LOSS HISTORY Company Indicate the carrier name, line of business, coverages and policy term. Losses Describe any losses, the loss date and amount paid. Corrective Action List any action taken to correct losses from reoccurring. Cancelled, Non-Renewed, Declined Indicate if the applicant has been cancelled, non-renewed, declined or placed in a non-standard market over the past three years. LOCATION Address (Include county and zip) Enter the physical street address (not P.O. Box) where the applicant is located. Address should include: Street number, if any Pre-direction, if any (example: 150 N Central Ave) Street name, if any Street type (examples: st, rd, ave) Post-direction, if any (example: 150 Central Ave N) City County State Zip Code If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Interest Indicate the interest the applicant has at this location. Year Built Enter the year the building was originally constructed. Area Occup. Enter the percentage of the building the applicant occupies. Sq. Ft. Enter the square footage of the building. Surrounding Exposures and Other Occupancies Describe the buildings, structures, activities conducted, or use of property adjacent to the insured premises and provide the distance from the insured premises. Also include any other occupancies not operated by the insured within the building where the insured is located. NATURE OF BUSINESS Indicate the primary nature of the applicant's operation. Options available are: Office

Apartments Service Condominiums Retail Contractors Wholesale Other (describe) DESCRIPTION OF OPERATIONS/OCCUPANCY This section is designed to tell the underwriter what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual; it does not provide adequate detail. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. Do operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material? If so, indicate how they are controlled, stored or disposed of. Indicate if the applicant owns or operates any landfills or fuel tanks. Are athletic teams sponsored? Indicate if the teams are composed of employees or others such as Little League. Are Certificates of Insurance required from sub contractors? Indicate who checks them, and if coverages are equal to or greater than the applicants. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question. Describe any location or business interest owned or operated by insured but not listed List any location or risk that is not to be covered within this package policy. Annual Sales/Receipts List the projected sales over the next 12 months. Total Payroll List the projected payroll over the next 12 months. PROPERTY For each unit at risk list the following: Amount The coverage limit. Valuation Type Replacement Cost (RC) or Actual Cash Value (ACV). Infl. % The Inflation Guard Percentage that is to apply. Coins The Coinsurance percentage that is to apply. Ded The Deductible limit that is to apply. Cause of Loss The cause of loss that is to apply, such as Basic, Broad, Special, or All Risk. Construction Indicate the building's construction type. Fire District/Code Number The property's fire district name and corresponding code number, which can be found in the individual states manual pages. Pr. CL. Enter the fire rating protection class for this location. Total Area

The area in square feet that the applicant occupies. Roof Type The construction of the roof. # Stories Not including any basement, enter the number of stories for this building. # Units The number of rental units if this is an apartment or condominium. Percentage of Building Sprinklered The percent of the building that is protected by a fire sprinkler system. Building Improvements Indicate if any building improvements have been made since the original construction. Check all applicable improvements and list the year the improvement was made after the improvement name. Bldg Code Grade Enter the ISO Building Code Grade, if applicable. Tax Code Enter the city, county or state tax code, if required. Wind Class Check the applicable box. OPTIONAL COVERAGES This section is used to collect information on additional Property, Inland Marine, Crime and Boiler and Machinery coverages. Glass By ground floor and above ground floor panes indicate the following: # Panes The number of like size panes Area The total area per pane Length The horizontal measurement per pane in inches Type The use of the pane such as display window Value The cost per pane Deductible The deductible for glass coverage Add'l. Info Any additional underwriting or rating data that may be beneficial. Property/Inland Marine Options Enter the limit, coinsurance percentage, and deductible for the following Property or Inland Marine options. Extra Expense Loss of Income Valuable Papers Accounts Receivable Signs Crime Enter the limits and deductibles for the following Crime coverages. Employee Dishonesty (include the number of employees) Burglary/Robbery of Stock Burglary/Robbery of Money Boiler and Machinery Enter the limit and deductible based on Basic or Broad Coverage. If Spoilage is requested, also enter that limit and deductible. State if there is a separate heating boiler. Bailees

List the total value of customers' goods stored on the insured premises. If the applicant operates a seasonal storage operation, enter "yes" for the question about stored beyond normal handling time. Transit For Transit coverage, provide the requested values. CRIME Complete this section in regards to the location and protection systems for this risk. Information on the classification of safes, vaults and alarm systems can be found in the Crime Section of the ISO Commercial Lines Manual. Alarm Type Indicate the type of alarm(s) protecting this premises, safe or vault. Available options are: Hold-Up The presence of a manual or semiautomatic control which can transmit an alarm in the event of a hold-up Burglar - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry Central Station - An alarm system that protects the safe or vault and is connected to an outside central station Alarm Description Indicate any applicable features of the alarm Local Gong - A bell located outside the premises Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private control station With Keys - Indicate if security service or police have Keys to respond to alarms Grade Enter the GRADE or class (e.g., A, B, C, etc.). This indicates the time required to respond to a signal from the alarm system. Please refer to company manual. Extent of Protection for Safe/Vault Indicate the extent of the alarm protection for the safe or vault. Partial - Alarm covers around door only Complete - Alarm covers sides, top walls, floor, and ceiling Extent of Protection for Premises Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual. Alarm Certificate #/Expiration Date Alarms which are approved by the Underwriters Laboratories (UL) or other testing organizations are evidenced by a certificate. Record the certificate number and its expiration date. Safe/Vault/Receptacle Manufacturer List the manufacturer's name of the applicant's safe, vault or other secured receptacle. Label Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe Manufacturers National Association (SMNA). Class Record the construction classification which represents the extent of burglary protection for this safe or vault. Be sure to use the classification from the Burglary label and not the Fire label located on the safe or vault. For industry definitions of the classifications refer to the Commercial Lines Manual. Maximum Cash on Premises Indicate the maximum amount of cash kept on the premises during normal business hours. Maximum Cash With Messenger Indicate the maximum amount of cash messengers are allowed to carry for the applicant. Money on Premises Overnight Indicate the maximum amount of cash left on the premises overnight. Frequency of Deposits Indicate the frequency with which deposits are made to the bank (e.g., daily, twice a week). Dbl. Cyl. Door Locks Indicate if all doors leading into and out of the applicant's premises have double cylinder door locks. Other Protection List any other protection device that the applicant uses. GENERAL LIABILITY As part of the package policy, the General Liability section must be completed. Limits

List all limits as they are to appear on the policy. For Combined Single Limit (CSL) policies list "CSL" and the appropriate limit in the "Other" coverage and limit section. Territory Enter the rating territory code from the appropriate state exception page for each described exposure, based on location. Class Code Enter the general liability Class Code that corresponds to the class description shown in the next field. (The class codes for Premises/Operations and Products/Completed Operations should be the same). Class Description Classify the applicant's liability exposures using the ISO Classification Table or other industry organization rules by location. Enter the appropriate class description from the table in this field. Exposure Base Enter the basis for how this class code is rated. Common exposure bases are: Gross Sales - per $1,000 Payroll - per $1,000 of pay Area - per 1,000 square feet Total cost - per $1,000 of cost Unit - per unit Exposure Enter the full exposure for the class. WORKERS COMPENSATION Complete this section for Workers Compensation coverage. The Workers Compensation information used on this application is the same data as included on the Workers Compensation Application (ACORD 130). Please refer to the chapter on the ACORD 130 for specific element descriptions. AUTOMOBILE Use the appropriate ACORD state-specific commercial auto forms to apply for auto coverage. UMBRELLA Complete this section for Umbrella coverage. The Umbrella information used on this application is based on the data included on the Umbrella Section (ACORD 131-S). Please refer to the chapter on the ACORD 131-S for specific element descriptions. SPECIFIC PROGRAM QUESTIONS Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. APTS/CONDOS Are there any swimming pools? List the number of pools and if there are any diving boards. Is aluminum wiring used? Indicate the date when wiring was done, and indicate if there is also copper wiring. # Units in Building or Fire Division If the building is divided into fire divisions, provide the number of apartment units in the largest fire division. If not, provide the number of apartments in the building. Coverage applies to Indicate if the coverage applies to bare walls or finished walls. Smoke Detectors Indicate if smoke detectors are provided in each apartment unit, and whether they are battery operated, or wired into the building's electrical system. ADDITIONAL INTEREST Complete this section for any additional interests to the package policy. Name & Address Give the additional interest's name and mailing address. Interest Indicate what the interest item is and the interest type. Example: Building Mortgagee Vehicle Number 2, Loss Payee Evidence

Indicate if a Certificate of Insurance or Evidence of Property Insurance is required. REMARKS Use this section to provide any additional information required for underwriting or rating.

Statement / Schedule of Values 139 (7/2000)

This form was developed to assist in the collection of information when multiple locations owned or operated by the same insured will be included in an average or blanket rated property insurance policy, or will be shown in a property schedule. This form is not intended to replace specific ACORD applications, such as ACORD 140, Property Section, or ACORD 160, Business Owners Application. Use this space for your notes. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. NAIC Code The company code assigned by the National Association of Insurance Commissioners. Page If more than one ACORD 139 form is required because of the number of properties to be included, indicate the page number applicable and the total number of pages (e.g., Page 1 of 5, Page 2 of 4). Insured/Applicant Show the name of the insured or applicant as it will appear on the policy. Effective Date Enter the effective date that will apply to the average or blanket rate, or will apply to the policy if the form is used to provide a schedule. Coins % Check the applicable coinsurance percentage, 80%, 90% or 100%. Applicable Cause of Loss Indicate the causes of loss for the subject of insurance. Specific Average Rate/Blanket Rate/Other Check the appropriate box. If a specific average rate or a blanket rate is not being requested, check the "other" box and state why the form is being used. Applicable Form Numbers Use this space to provide information about endorsements, options, and any information affecting rates or loss costs that cannot be shown in the schedule on the form. Class Code Enter the ISO or Company Class Code, if applicable. Location #/Bldg. #/Description and Location of Property For each building, enter the location number, building number and address as shown on the application or change request that was used when the building was first insured. Provide a description of the property where necessary. Use more than

one line if additional space is required. ACV/RC Indicate "ACV" if actual cash value valuation is to apply. Enter "RC" if replacement cost valuation is to apply. If another valuation basis applies, provide the necessary information. Subject Enter the appropriate code to identify the subject of insurance as shown in the instructions on the bottom of the form. 100% Values Provide the value for each property in accordance with the valuation method and the subject of insurance. Rate or Loss Cost For class rated property, attach class rate information or equivalent information for each location. For specifically rated property, attach specific rate or loss cost information if known. Premium Enter the premium for each property in this column.

Supplemental Property Application 190 (1/96)

The Supplemental Property Application is a uniquely designed ACORD application. "Yes" responses to the underwriting questions on the front side should be explained in detail in corresponding sections on the back of the application. Both sides of this application must be completed. The instruction information below is formatted by sections; it does not deal with the front side first and then the back. IDENTIFICATION SECTION Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Insured/Applicant First Named Insured and mailing address as it appears on the Commercial Applicant Information Section, Dwelling Fire Application or Homeowners Application. Policy Number If a policy number has already been assigned to this insured/applicant, enter the number exactly as it will appear on the policy, including prefixes and suffixes. Location of Property Give the location of the property if it is different than the mailing address, or if the mailing address is not sufficiently descriptive. UNDERWRITING INFORMATION A. Ownership Information List the name, address, position and interest percentage of all major owners for risks other than individuals or partnerships. B. Mortgage Payments/Tax Liens Mortgage Payments For late payments list the Mortgagee's name and address, the date the late payment was due and the amount due. Also, list any other encumbrances that may be on the property. Tax Liens/Overdue Taxes Check if this is a tax lien or overdue tax. List the lienholder or who the tax is owed to in the space under the check-off boxes. Enter the date and the amount that was due in the available spaces. C. Violations Give the date the violation was issued and briefly describe the violation. D. Convictions/Losses Convictions Date, description and name of the individual convicted of arson, fraud or property related crime.

Losses List all fire and explosion losses exceeding $1,000 by date of loss, amount of loss, location and description. E. Lender List the lender's name and explain its relationship to the insured. F. Vacancy/Unoccupancy Season When Unused For seasonal property and risks when vacancy or unoccupancy is planned, enter the time span when the property is not in use. Total # of Apartment Units List the number of apartments in the building or complex. # Unoccupied Apartment Units List the number of units that are currently unoccupied. Other Buildings, % Vacant For buildings excluding apartments, list the percentage of the building that is vacant (unoccupied and no furniture). Other Buildings, % Unoccupied For buildings excluding apartments, list the percentage of the building that is unoccupied (furnished but no residents). Anticipated Date of Occupancy If any tenants are scheduled, list the occupancy date. Reason for Vacancy/Unoccupancy List any reasons for the vacancy or unoccupancy, such as seasonal rental property or building renovation. How is Building Protected from Entry? List any security measures to protect the building from unlawful entry. Is there a government order to vacate or destroy the building, or has the building been classified as uninhabitable or structurally unsafe? If any of these conditions exist check the "Yes" box. Are any utilities out of service? If the electrical, water or gas services have been shut off, explain circumstances in the available space. Is there unrepaired damage or have items been stripped from building? If the building is in any form of disrepair or under renovation, describe the damage or process in the available space. Is the building up for sale? Enter the listing date. G. Other Insurance For other property insurance list the Status (bound, submitted, in force), the effective date, amount of insurance, company and policy number. BUILDING INFORMATION H. Purchase Date Date of purchase, all transaction dates and seller information over the past three years. Purchase Price Amount the insured paid for the property. Rental Income Expected annual rental income. Approximate Cost of Subsequent Improvements Costs of improvements to the property since first purchased. Approximate Replacement Costs Estimated cost to rebuild the building in case of total loss. Approximate Fair Market Value (Exclusive of Land) Cost to purchase a similar building without the land. Insurance Value Indicate the price used to determine the insurance limit. Value Determination Check all methods used to determine the property value and attach copies of any appraisals performed. List the appraiser's name and any other additional appraisal.

Transportation Section 143 (9/91)

This chapter provides the user with basic instructions for completing the ACORD Transportation Section (ACORD 143). The section addresses the basic underwriting and rating needs for monoline or package policies with the Inland Marine coverages of Transportation and Motor Truck Cargo Legal Liability. Applicant Information Section (ACORD 125) and the Vehicle Schedule (ACORD 129). Refer to the chapters on these forms for specific information on completing them. IDENTIFICATION SECTION Much of the information for this section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Since many companies separate the applications by line of business for rating purposes, not completing this part of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Effective date on which the terms and conditions of the policy will commence. Proposed Exp. Date Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code: A = annual S = semi-annual Q = quarterly M = monthly O = other INTEREST This part of the form applies to both Transportation Insurance and Motor Truck Cargo Legal Liability. The balance of the front of this application is used to request Transportation Coverage, and the entire reverse for Motor Truck Cargo Legal Liability. Indicate the relationship of the applicant to the property being shipped. Common Carrier General right to operate as a carrier for any shipper over certain routes and for types of non-exempt commodities. Contract Carrier Right to haul interstate for certain customers. The trucker is limited to no more than 10 contracts. Shipper of Owned Property Indicate if an insurable interest in the property has been shipped on owned vehicles or other vehicles while in transit by virtue of ownership. Other List any other trucking relationship(s) in detail. TYPE Indicate the type(s) of Insuring Agreement desired. Transportation Applies when insurance is desired on property owned by the applicant, whether the property is shipped in the applicant's vehicles or in public conveyances. Provides no Legal Liability coverage. Motor Truck Cargo Legal Liability Applies when insurance is desired on property in the care, custody or control of the applicant, and for which the applicant is responsible as a carrier for hire. Open or Annual

Indicate if policy is being written on an Open or Annual basis. Open Continuous monthly reporting policy. The values change monthly, as reported. Annual Policy written with a specified term limit. Other Provide pertinent information regarding coverages or explain the applicant's other interest. TRANSPORTATION This section should be used to request Transportation Insurance, or coverage on goods owned by the applicant, whether the goods are shipped in the applicant's own vehicles or on public conveyances. This insurance covers property only and does not provide coverage for Legal Liability. OPERATIONS Property Shipped Specifically describe the property to be insured while in transit, and indicate if the property is also produced by the applicant. Attach a supplemental page if necessary. Points of Origin Origination point of the property to be shipped. Points of Destination Destination to which the property is to be shipped. Territory Area of operations for transported merchandise. This may be specific (e.g., a certain city, state or route); or general (e.g., eastern states from Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the territory should also be provided, as well as the number of drivers within the territory. Annual Gross Sales Estimated annual amount of sales. Conveyances Used Complete sections that apply next to the mode of transportation used to transport the property to be insured. Annual Value Shipped at Applicant's Risk Specify per classification, the total annual dollar amount of incoming, outgoing or interplant cargos shipped or received by the applicant. Incoming Dollar value of all yearly incoming shipments. Outgoing Dollar value of all yearly outgoing shipments. Interplant Dollar value of all yearly shipments sent between the applicant's plants. Average Value per Shipment Average value of shipments on any type of conveyance used by the applicant. Limit of Liability Limits should be 100 percent of the maximum value carried. Bill of Lading Written document explaining the terms of shipment. Specify the released Bill of Lading for the property shipped per conveyance type (e.g., 60 cents per pound. If full value is insured, indicate on the appropriate line). Perils Indicate the perils the coverage is to be written on. Options are All Risk, Named Perils and Named Perils Including Theft. Deductible Deductible for the transportation coverage. Number Operated Specify the exact number of vehicles used or operated by the applicant for each of the groups listed. Vehicle types are: Trucks Tractors Trailers Tank Trucks Refrigerated Units

Special Units Owned/Operated List all other vehicles owned or operated by the applicant for which this insurance applies (e.g., extra-wide or extra-long or large tank trucks, mobile cranes, tandem trailers and house movers). VEHICLE SCHEDULE Use this section to identify vehicles which transport property of the applicant. The section can be supplemented by the ACORD Vehicle Schedule (ACORD 129) which highlights important features in the ACORD Vehicle Schedule related to this coverage line. Not all information found in the ACORD Vehicle Schedule is necessary to complete this application. Number Number assigned by the agent to this vehicle to track during the application process. Model Year Vehicle's model year. Vehicle Type Manufacturer's name, their model name and vehicle body type. ID#/Serial Number Vehicle identification number (vin) or serial number assigned by the manufacturer. Date Purchased Date the vehicle was purchased. New/Used Indicate if the vehicle was purchased new or used. Radius of Operations Average radius in miles that this vehicle travels. F.O.B. If materials are shipped F.O.B. (Free on Board) point of destination, the seller is liable for damages caused during transportation. If materials are shipped F.O.B. point of departure, the buyer is liable for damages. Indicate if contingent coverage is desired on F.O.B. shipments. Contingent coverage is either "in excess of" or "in lieu of" coverage provided by the shipper and affords protection when the shipper's insurance is incorrect or inadequate, or when differences in conditions (DIC) exist. Enter the percentage of annual gross sales represented by F.O.B. shipments. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered "Yes." The overview below lists information that should be added to the Remarks section for "Yes" responses. 1. Is there a vehicle maintenance program in operation? Explain the type of program and if maintenance records are kept on file. 2. Does applicant obtain MVR verification for drivers? Indicate if applicant reviews MVRs on all assigned drivers and frequency. Indicate if review is upon hiring only. If no, explain. 3. Does applicant have a driver recruiting method? Describe the recruiting method and indicate if written and/or road tests are conducted. 4. Do drivers receive a regular physical? Indicate the frequency of the physical. 5. Any waterborne shipments to be covered? Specify the body of water and the method of transportation. 6. Are vehicles equipped with theft alarms? List the type of alarm installed. 7. Are vehicles left unlocked when unattended? If yes, give circumstances. 8. Are vehicles left loaded overnight? If yes, give circumstances. Indicate where trucks are parked, describe any security provided, and who is responsible. 9. Does applicant back haul property of others? Indicate contract terms. REMARKS Use this section to provide any additional information required for underwriting or rating. MOTOR TRUCK CARGO LEGAL LIABILITY This section is used to request Motor Truck Cargo Legal Liability insurance, or coverage on property in the care, custody or control of the applicant, for which the applicant is responsible as a carrier for hire.

OPERATIONS Property Hauled Specifically describe the property of others that the applicant hauls. Gross Receipts Last 12 Months Amount of gross receipts for shipments handled the past 12 months. Gross Receipts Next 12 Months Estimated amount of gross receipts for next 12 months of shipments. Territory Area of operations for transported merchandise. This may be specific (e.g., a certain city, state or route); or general (e.g., Eastern states from Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the territory should also be provided as well as the number of drivers within the territory. Average Distance State in miles the average distance the applicant hauls. Maximum Distance State in miles the farthest distance the applicant hauls. List Target Commodities Carried List all property hauled which might be exposed to additional risk, including pharmaceuticals, stereos, computers, meat, seafoods, televisions, audio-visual equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts, clothing and furs. Percent of Gross Revenues Percent of gross revenues earned from transporting each target commodity. Maximum Value per Vehicle Maximum value of each target commodity carried on any one vehicle. State Filings Required List all states requiring filings for the regulation of the trucking industry. Indicate if a P.U.C. (Public Utility Commission), P.S.C. (Public Safety Commission) or I.C.C. (Interstate Commerce Commission) fileing is required. Enter all known docket numbers for these filings. Limit of Liability Amount of insurance required for each applicable category. If different limits exist for different vehicles, show the limits of liability per vehicle in the Remarks section or on a separate sheet of paper. Per Single Conveyance Amount of insurance required per conveyance which is the aggregate limit being moved by a motorized unit (e.g., Truck with Semi-Trailer or Full Trailer). Per Disaster Specify the overall disaster limit required. Loading/Unloading If loading or unloading coverage is desired, place an "X" in the box, and indicate the limit of liability and deductible desired. Perils Indicate the perils the coverage is to be based on. Options are: All Risk, Named Perils, Named Perils including Theft and Loading/Unloading. Deductible Deductible for the chosen perils coverage. Number Operated Specify the exact number of vehicles used or operated by the applicant for each of the groups listed. Vehicle types are: Trucks Tractors Trailers Tank Trailers Refrigerated Units Special Units Owned/Operated List all other vehicles owned or operated by the applicant for which this insurance applies (e.g., extra wide trailers, large tank trucks, mobile cranes, tandem trailers and house movers). TERMINALS Terminal locations are buildings (or enclosed areas) owned or used by the applicant and operated as points of holding, distribution, warehousing, or layovers for property off vehicles.

Location # Assign a number to each terminal location. If locations are the same as shown on the Applicant Information Section (ACORD 125), use the same number in the space provided. Address Give the address of each terminal for each location. Average Value At Terminal Average value of goods held at each terminal location. Maximum Value Maximum value of goods held at each terminal location. Limit of Liability Limit required for each terminal location. The limits should be 100 percent of the maximum value carried. VEHICLE SCHEDULE Use this section to identify vehicles used by the applicant to transport property of others. This section can be supplemented by the ACORD Vehicle Schedule (ACORD 129), and highlights important features found in the ACORD Vehicle Schedule related to this line of coverage. Not all information found in the ACORD Vehicle Schedule is necessary to complete this application. # Number assigned by the agent to this vehicle to track during the application process. Model Year Vehicle's model year. Vehicle Type Manufacturer's name, model name and the body type for this vehicle. ID#/Serial Number Vehicle identification number (vin) or serial number assigned by the manufacturer. Date Purchased Date the vehicle was purchased. New/Used Indicate if the vehicle was purchased new or used. Radius of Operations Indicate the average radius in miles that this vehicle travels. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered "Yes." The overview below lists information that should be added to the Remarks section for "Yes" responses. 1. Is there a vehicle maintenance program in operation? Explain the type of program and if maintenance records are kept on file. 2. Does applicant obtain MVR verification for drivers? Indicate if applicant reviews MVRs on all assigned drivers and frequency. Indicate if the review is upon hiring only. If no, explain. 3. Does applicant have a driver recruiting method? Describe the recruiting method and indicate if written and/or road tests are conducted. 4. Do drivers receive a regular physical? Indicate the frequency of the physical examinations. 5. Are vehicles equipped with theft alarms? List the type of alarm installed. 6. Are vehicles left unlocked when unattended? If yes, give circumstances. 7. Are overages, shortages and damage claims pending? Enter the amount of any such outstanding claims. 8. Are any vehicles operated for the applicant by others? Indicate if any vehicles are owned, leased or operated solely for the applicant by private or contract carriers. Give agreement conditions. 9. Do terminals have fire protection (sprinklers, hoses, etc.)? Describe all such fire protection devices.

10. Do terminals have security systems (guards, alarms, fences, lights, dogs, etc.)? Describe all such security systems. 11. Are vehicles left loaded overnight? Indicate where trucks are parked and describe any security provided. 12. Is applicant an owner operator? Complete vehicle section. 13. Does the applicant hire owner operators? Give the conditions of all agreements with owners and indicate if an insurance certificate is required. 14. Does the applicant triplease to others? Give the conditions of all agreements with owners and indicate if an insurance certificate is required. 15. Does the applicant back haul property of others? Give the conditions of all agreements with owners and indicate if an insurance certificate is required. REMARKS Use this section to provide any additional information required for underwriting or rating.

Truckers/Motor Carriers Section 132 (3/2001)

This guide provides the user with basic instructions for completing the ACORD Truckers/Motor Carriers Section. This Section has been designed to handle the basic underwriting and rating needs for liability and physical damage coverages for trucking or motor carrier operations. If a transportation or motor truck legal liability exposure exists, the Transportation Section, ACORD 143 (9/91), may also need to be completed. Insurance coverages, "no fault" and uninsured/underinsured motorists coverages in particular, vary widely from state to state. In addition, there are numerous state-specific requirements that apply to Truckers or Motor Carrier applications. ACORD 132 cannot address these various unique specifications. Therefore, state specific forms, ACORD 137, have been developed to respond to these requirements. Use the ACORD 137 for your state to provide coverages/limits information, as well as the required disclosure and other data unique to the state. See the State Forms section of this Guide for more information. This form was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125) and the Vehicle Schedule (ACORD 129). Please turn to the chapters on these forms for specific information on completing them. Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in all states. Refer to the State Forms section of this Guide. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number.

Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to the agency or brokerage firm by the Insurance Company receiving this form. Sub Code If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Enter the Effective date on which the terms and conditions of the policy will commence. Expiration Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Date Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. Examples: Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30. Audit Use this field to indicate the audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other REGULATION This section is used to indicate the relationship between the applicant and the property being shipped and to indicate any regulatory filings required. Indicate the method of operation by checking the applicable box(es). Also attach ACORD 194, Request for State/Federal Filing Action, to provide the necessary filing information. Common Carrier Has the general rights to operate as a carrier for any shipper over certain routes and for types of non-exempt commodities. Contract Carrier Has the rights to haul interstate for certain specific customers. The trucker is limited to no more than 10 contracts. Private Carrier Indicates an insurable interest in the property being shipped on owned vehicles or other vehicles while in transit by virtue of ownership. DOT Rating, Docket #, ICC Filing Provide this information if applicable. Other List any other trucking relationship in detail in the Remarks Section. COVERAGE/LIMITS

Covered Auto Symbols Truckers policies use numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 41 through 45 provide Fleet Automatic coverage. Symbol 41 includes Hired and Non-Owned auto coverage. If symbol 41 is not used and Hired Auto (symbol 47) or Non-Owned Auto (symbol 50) coverage is desired, those symbols must be checked. The symbols indicate the automobiles to which each coverage applies. The symbol "triggers" the coverage. For exact policy definitions of the symbols, please refer to the company's policy declarations page. Symbol 41 - Any Auto Can only be used for Liability insurance. Its use provides coverage for any auto with which the insured will have contact, including owned and non-owned and hired vehicles. It includes coverage for non-owned autos, no-fault, uninsured motorists or physical damage insurance. Symbol 42 - Owned Autos Only Provides coverage for owned autos only and includes automatic coverage for autos you newly acquire. Symbol 43 - Owned Commercial Autos Only Provides coverage for owned commercial autos only and includes automatic coverage for commercial autos you newly acquire. Symbol 44 - Owned Autos Subject to No-Fault Laws Applies to owned autos where no-fault is required by law, including automatic coverage for autos you newly acquire. Symbol 45 - Owned Autos Subject to Compulsory Uninsured Motorist Laws Applies to owned autos where there is a compulsory Uninsured Motorists law including automatic coverage for autos you newly acquire where rejection of UM is not permitted by law. Symbol 46 - Specifically Described Autos Provides coverage for scheduled autos only, with no automatic coverage for autos you newly acquire. Symbol 47 - Hired Autos Only Provides coverage only for autos leased, hired, rented or borrowed by the named insured. This does not include autos owned by employees or members of their families. Symbol 48 - Trailers in Your Possession Under a Trailer Interchange Agreement Provides for trailers listed under a trailer interchange that are left in the applicant's possession. Symbol 49 - Trailers in the Possession of Another Trucker Under a Trailer Interchange Agreement Provides coverage for your trailers when listed under a trailer interchange that are in the possession of another trucker. Symbol 50 - Non-Owned Autos Only Provides liability coverage for autos not owned by the named insured but used in connection with the trucking business. This includes autos owned by employees. Coverage/Limits - Use ACORD 137 RECEIPTS, MILEAGE UNITS For each of the past three years, enter the gross receipts, total mileage for all vehicles, and the total number of power units. Also enter estimates for next year. Commodities Describe each of the major commodities transported. Enter the percent of total revenues and the estimated value per truckload.

TERMINALS This section is used to collect information on the terminal locations that the trucker uses. # Assign a number to identify each terminal location. If this location corresponds to one listed in the Applicant Information Section of ACORD 125, use that number. Name and Address of Terminals Enter the name and address of each terminal used. # Veh Specify the number of vehicles regularly using or garaged at each terminal. Dist. From Garage Enter the appropriate distance between each terminal and the place of principal garaging. DRIVER INFORMATION This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business. Driver # Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes. Name Enter driver's full name. If the company requires the address, enter it as well. Sex Enter F for female, M for male. Mar Stat Enter the marital status for each listed driver. Examples: S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed Date of Birth Enter driver's birth date. Yrs Exp Enter the number of years of driving experience for each driver. Year Licensed Enter year in which the driver was first licensed. Driver's License Number/Soc. Sec. # Enter complete driver's license number. If a license number is unavailable, enter the driver's social security number. State Lic. Enter the state in which the license was issued. Date Hire Enter the date of hire for each listed driver (MM/DD/YY). Use Vehicle # Enter the vehicle number that this driver primarily uses. % Use Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses. EQUIPMENT Use this section to summarize information on the trucks and tractors used by the applicant. Individual specifics on each truck or tractor should be completed in the Vehicle Section, ACORD 129. List the number of vehicles falling into each category.

Company Owned Specify the number of vehicles, per type, owned by the applicant. Non-Owned Specify the number of non-owned vehicles, per type, operated by the applicant. Long Term Leased Specify the number of long termed leased vehicles operated by the applicant. Trip Lease Specify the number of vehicles operated on a trip lease basis by average number per month. Radius (miles) By vehicle type, indicate the number of vehicles that fall within the categories of local, intermediate, and long distance, in accordance with the companies' manual rules. TERRITORY/ZONE Specify the territory in which the applicant normally operates. This may be a certain city, county or state. If the applicant has any special routes or areas of confined operation, so indicate. List any specific geographic areas that the applicant may operate out of such as Mid-western States or East Coast. For zone rated risks, provide the appropriate numbers or identification information. Zone rating is designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from the point of principal garaging. It does not apply to light trucks or trailers used with light trucks. GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. 1. Is there a vehicle maintenance program in operation? Explain type of program and if maintenance records are kept on file. 2. Does the applicant obtain MVR verifications on drivers? Indicate if applicant reviews MVRs on all assigned drivers and how often. Indicate if review is upon hiring only. If No, provide explanation as to why MVRs are not reviewed. 3. Does the applicant have a driver recruiting method? Describe the recruiting method. Indicate if written and/or road tests are conducted. 4. Are any drivers not covered by Workers Compensation? Provide the names of all drivers not covered. 5. Does applicant own or operate equipment not listed here? List all equipment not to be covered and explain why. Indicate where coverage is placed for this equipment. 6. Does applicant haul any dangerous, caustic, radioactive or flammable cargo? Specify the type of cargo hauled, the percentage of business involved in this cargo and the estimated annual revenue derived from hauling this cargo. 7. Does applicant haul target commodities? Indicate if the applicant hauls any property subject to high incidence of theft. Specify the type of cargo hauled, the percentage of business involved in this cargo and the estimated annual revenue derived from hauling this cargo. 8. Do drivers receive a regular physical? List the frequency of the physical examinations. Example: annual or semi-annual. 9. Does applicant hire equipment from others? List the source and kind of equipment. 10. Does applicant rent or lease vehicles or equipment to others with/without operators? List the vehicles or equipment, drivers name (if any), and who is carrying the primary coverage.

11. Does applicant haul for other truckers? Identify the work done for others and the percentage of estimated annual revenue involved in working for others. 12. Do other truckers operate under the permit of the applicant? Specify the percentage of the total number of vehicles operated by others under the permit of the applicant. 13. Is coverage required for travel in Canada or Mexico? List countries where coverage is required. 14. Are drivers compensated per trip? Indicate how the drivers are paid: per trip, by mile, by salary, or by contract. Give terms of agreement for remuneration. 15. Any Hold Harmless agreements? If any are in effect, state the provisions or attach a copy of the agreement. 16. Any Drivers with moving traffic violations? Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company's and state's requirements. 17. Do any vehicles have special equipment mounted or attached? Indicate which vehicles have been altered, customized or equipped with special equipment. 18. Does applicant pull double or triple trailers? If yes, describe the operations, including the percentage of vehicles in each category. 19. Does applicant have tow trucks or perform towing? Indicate how many tow trucks are owned or used by the applicant and describe towing operations. 20. Are vehicles left unlocked when unattended? If yes, describe how vehicles and contents are protected from unauthorized entry. 21. Are any overage, shortage or damage claims pending? If yes, describe, and provide dollar amounts. ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an ACORD 45. Interest Indicate all appropriate options for the individual named. Rank Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee. Name and Address List the additional interests name and address. Reference # Indicate the additional interests reference number for this applicant such as the loan or mortgage number. Certificate Required If a Certificate of Insurance is required check this box. Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured. Item Description If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting.

REMARKS Use this section to provide any additional information required for the underwriting or rating of this risk.

Umbrella Section 131 (8/2001)

An Umbrella is a liability coverage affording high limit excess and/or extended coverage. It is a separate policy over and above other basic liability policies the same insured may have. A completed Umbrella Application consists of both the Applicant Information Section ACORD 125 and the Umbrella Section ACORD 131. This is necessary because some information about the applicant is only shown on the Applicant Information Section. IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of the ACORD 125. Even though this data matches the data on the ACORD 125, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Date Month/day/year on which the form is completed. Producer Producer's name, address fax and telephone number. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Proposed Eff. Date Enter the Effective date on which the terms and conditions of the policy will commence. It is important that the effective dates of the underlying policies are concurrent with those of the Umbrella policy when aggregate limits are involved. If the effective dates of the underlying policies and the Umbrella are not concurrent, the full underlying limits may not be available for losses that occur during the policy period of the Umbrella and a coverage gap may occur. Proposed Exp. Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Use this field to indicate the audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other POLICY INFORMATION

Transaction Type Indicate by checking the appropriate box if this is New business or a Renewal request. Expiring Pol # For renewal requests, indicate the expiring umbrella policy number. Proposed Retroactive Date If Claims Made coverage is being requested, enter the proposed retroactive date. Current Retroactive Date The current retroactive date should be shown if the Umbrella is over a Claims Made primary policy. If the current retroactive date is different from the proposed retroactive date, an explanation must be provided. Limit of Liability Liability is generally on a per occurrence basis. Other options are: per accident, total products liability hazard, aggregate limits, etc. Enter the policy limit and specify the limit type if it is not on a per occurrence basis. In Florida, Indiana, Louisiana, Ohio, Vermont, and West Virgina Uninsured Motorists coverages must be offered in umbrella policies up to the liability limit of the policy, when auto liability coverage is included. In Florida auto supplement ACORD 61 FL should be used with Umbrella policies. Refer to the instructions for use of this form in the State Supplement section of this guide. In the other states mentioned above, no supplement is required, but the insured must initial the appropriate statement at the bottom of the back of this form, indicating selection or rejection of UM coverage. Retained Limit The retained limit on an Umbrella policy functions like a deductible. If a loss occurs that is covered under the Umbrella, but not covered under the primary, the Umbrella policy responds in excess of the retained limit. First Dollar Defense Most Umbrella policies provide first dollar defense coverage. Some insurers may not offer an alternative. This coverage is generally in connection with self-insured retention. Place an "X in the "yes" box if the applicant desires first dollar defense. Primary Location and Subsidiaries This section is completed to give additional location information not found on the ACORD 125. # Enter the primary location numbers as they appear on the ACORD 125. Name and Location of Primary and All Subsidiary Companies Describe the operation of each of the insured's companies. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders). Large industrial concerns, which are involved in many types of operations, may only indicate exposures from their major division or operation. The real exposure from an excess standpoint may be a minor portion of the insured's operation (e.g., an insured that owns or acquires a subsidiary involved in the manufacture of medical diagnostic equipment). If the locations are not listed on the ACORD 125, be sure to include their addresses. Annual Payroll Provide the estimated annual payroll figures for each entity and operation. This information is useful to underwriters in analyzing the applicant's exposures. It is also useful when writing Umbrella coverage on an auditable basis. If there are foreign subsidiaries, state only the domestic sales. Ann. Gross Sales Provide the estimated annual gross sales for each entity and operation. Foreign Sales Most Umbrellas provide coverage "anywhere," and do not require a suit to be brought within the CGL territory definition of the U.S., Canada, and Puerto Rico. If no foreign sales are shown, it would indicate no operations outside the United States. If foreign sales are

shown, attach information on the products sold, countries involved, and the primary insurers of foreign products coverage. The limits of this coverage should be expressed in U.S. dollars. # Empl. Enter the number of employees at each primary and subsidiary location. UNDERLYING INSURANCE List all liability and Worker's Compensation policies in force that you intend to apply as underlying insurance. The information about underlying insurance should be as complete as possible since it will be used by the underwriter to price the Umbrella coverage and complete the Schedule of Underlying Insurance. Carrier/Policy Number Enter the name of the insurance company (carrier) and the policy number for each type of insurance. Policy Effective/Expiration Dates Enter the effective and expiration date of each of the underlying policies listed. * If these dates are not concurrent with the effective and expiration dates for the Umbrella coverage, it could result in a failure to provide unimpaired, underlying aggregate limits. Limits Enter the limits as found on the policy declarations pages for each listed underlying policy. Available coverages listed are: Automobile Liability · Combined Single Limit (CSL) · Bodily Injury (BI) · Property Damage (PD) General Liability · · · · · · Each Occurrence General Aggregate Personal & Advertising Injury Products & Completed Operations Aggregate Fire Damage Medical Expense

* For General Liability, indicate if the underlying coverage was issued as either an Occurrence policy or a Claims Made policy. Employers Liability · Each Accident · Disease Policy Limit · Disease Each Employee Annual Renewal Premium Enter the annual premium for the policy period shown for each underlying policy. Rating Mod Enter the Combined Rating Modification, and the experience modification debit or credit as they apply. * Space is provided in this section to add other liability policies in force. UNDERLYING GENERAL LIABILITY INFORMATION This section provides the Underwriter with a more detailed view of the underlying general liability policies listed above. Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. 1. Are defense costs Check the appropriate box to indicate how the general liability policy responds to defense

costs. Options: · · · Within Aggregate Limits A Separate Limit Unlimited

2. Indicate the edition date of the ISO form or similar filing for the underlying coverage Policy coverage may vary depending on the edition date of the policy paper. The underlying general liability coverage forms issued by ISO vary if they are based on the rules of "86" or the rules of "88." Enter the edition date of the underlying coverage form in the space provided. 3. Has any product, work, accident, or location been excluded, uninsured or self insured from any previous coverage? Explain any such situation in the Remarks section. 4. For Claims Made, indicate the retroactive date of current underlying policy Show the retroactive date of the current general liability policy if it is a Claims Made policy. 5. For Claims Made, indicate entry date into uninterrupted Claims Made coverage Indicate when uninterrupted Claims Made coverage became effective. This tells the underwriter where the applicant is in the Claims Made progression, such as year 3 or 4 of Claims Made coverage. 6. For Claims Made, was "tail" coverage purchased for any previous primary or excess policy? Give details and indicate when the Tail was purchased. The proposed retroactive date for the policy being applied for should not be earlier than the effective date of the Tail. UNDERLYING COVERAGES/EXPOSURE Use this section to indicate all underlying coverages and all known liability exposures. Use the box to the left of the coverage listing to indicate that the applicant has standard insurance coverage for the item. The limits must equal or exceed the limits indicated in the Underlying Insurance section above. If the limits are less, an exposure exists so the exposure box on the right should also be checked. Use the box on the right of each coverage listing to indicate if a known exposure exists. Additional known coverages or exposures should be indicated in the available space. Known exposures should be elaborated on in the Additional Exposures section on the reverse side of the application and within the Remarks section. Underlying Insurance Coverage Information List all underlying coverage forms, endorsements, subrogation waivers and extensions of coverages. Previous Experience List the loss history over the past five years involving liability claims exceeding $10,000 or occurrences that may give rise to claims. If there are no such claims or occurrences, "X" the available box. CARE, CUSTODY, CONTROL Many Umbrella policies include coverage for property of others in the applicant's care, custody, and control, even though such coverage is excluded by the underlying insurance. It is important to consider and describe this exposure when it exists. Some potential exposures in the applicant's care, custody, and control include: · Rented or leased equipment · Personal property of others · Leased premises · Goods on consignment · Property of others used or borrowed by the applicant · Each location that has a care, custody, and control exposure should be indicated Loc

Enter the location number if applicable to the ACORD 125. Real Property/Personal Property Check if the "value" listed is a building (real property) or personal property within the care, custody or control of the applicant. Value For real property, include the value of the entire building, not just the portion occupied. For personal property list the appropriate personal property value. A, B, C, D Indicate all of the following that apply in relation to the applicant's liability for the described premises: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant is held harmless in the lease. B . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant has a waiver of subrogation. C . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant is a named insured in the fire policy. D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other. Specify within the Occupancy/Description section. Sq Ft/Bld Occ Provide the total square footage of the premises occupied by the applicant. Occupancy/ Description of Personal Property Provide a description of the building occupancy or of the property held by the applicant in his care, custody and control. ADDITIONAL EXPOSURES This section gives the underwriter insight on exposures which may have been identified in the Underlying Insurance section or other exposures which may exist. Complete all sections with known exposures. Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The overview below lists the expected information that should be added to the remarks section for "Yes" responses. Advertising Liability If advertising is required by the applicant, complete this section. 1. Media used, annual costs Specify the media used for advertising such as newspaper or radio and the annual cost for all advertising. 2. Services of advertising agency used? Provide the name and address of the advertising agency used. 3. Any coverage provided under agency's policy? If advertising liability coverage is provided to the applicant by the ad agency, give the insurer, policy number and limits of liability. Aircraft Liability Complete this section for aircraft exposures. 4. Does applicant own, lease or operate aircraft? Provide a copy of the Aircraft Liability Application and description of aircraft to be insured. Auto Liability If automobiles or other vehicles are owned or operated by the applicant, complete this section. 5. Are explosives, caustics, flammables or other dangerous cargo hauled? Identify the type(s) of all such cargo (e.g., dynamite, acid). 6. Are passengers carried for a fee? Identify vehicles and circumstances. Indicate if vehicles are used to transport the general public or charter groups. 7. Any units not insured by underlying policies? Identify vehicles not covered under the underlying policies.

8. Are any vehicles leased or rented to others? Provide description of the nature of rental or lease agreement. 9. Is Hired and Non/Owned coverage provided? List the estimated cost of hire and to whom the non/owned coverage applies. Contractors Liability Complete this section if contracting is performed. 10. Is bridge, dam or marine work performed? Specify duties and hazards involving water exposures. 11. Describe typical jobs performed Give a brief description of the type of work performed for which this policy applies. 12. Describe agreement Explain all contractual agreements pertaining to the work performed. 13. Does applicant own, rent, or otherwise use cranes? Specify type of equipment used and the length of the boom. 14. Do subcontractors carry coverages or limits less than applicant? Indicate if certificates are required. Employers Liability Complete this section for Employers Liability exposures. 15. Is applicant self-insured in any state? Specify the states involved and give the amount of the self insured retention. Indicate if self insurance adequately satisfies state requirements. 16. Regulation: Place an "X" in the appropriate box to indicate if any employees are subject to one or more of the following programs: · Jones Act · Federal Employers Liability Act (FELA) · Stop Gap Incident Malpractice Liability If applicant provides medical aid, complete the following questions. 17. Hospital or first aid facility maintained? Describe the facility and services provided. 18. Coverage provided for doctors/nurses? List carrier and policy number for coverage provided to doctors or nurses. Identify those covered. 19. Indicate # of doctors, nurses, beds. Give the count for the listed items. Pollution Liability Complete this section if the applicant has any exposure to hazardous materials. EPA # Provide the number assigned by the Environmental Protection Agency. 20. Do current or past products, or their components, contain hazardous materials that may require special disposal methods? Specify the methods of hazardous material disposal. 21. Indicate the coverages carried: Check the appropriate boxes for the underlying general liability coverages. Product Liability Complete this section if the applicant produces or sells any product. List all products in the remarks section. 22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft?

Identify the systems or parts produced or installed. 23. Are foreign products distributed in U.S? Identify any foreign products that the applicant sells or distributes in the United States. 24. Are U.S. products sold or distributed in foreign countries? Identify the products involved and the nature of the applicant's operation. 25. Product liability loss in past 3 years? Provide details of all product losses, items involved, amounts paid and reserves established. 26. Gross sales from each of the last three years. List the gross sales or receipts for all products manufactured or sold in the past three years beginning with the most current receipts. Protective Liability Complete this section if contractors are hired by the applicant. 27. Describe independent contractors Identify all independent contractors and explain the agreements involved. Give nature of business and work performed. Watercraft Liability If the applicant owns, operates or uses watercraft, complete this section. 28. Does applicant own or lease watercraft? Give the number owned, length and horsepower of watercraft owned or leased. Apartments/Condominiums/Hotels/Motels Complete this section if the applicant rents any of the above units. List the number of stories, number of units, number of swimming pools and number of diving boards. VEHICLES Use this section to provide specific information on the number and type of Auto units. The three distance columns should be used to indicate the radius of operations for each vehicle type. If over 200 miles, enter the approximate distance. REMARKS Use this section to explain all "Yes" responses to any of the questions in the Additional Exposures section. Provide enough detail to enable the underwriter to fully understand the exposures indicated and the degree of risk involved. Attach additional pages if necessary.

Vehicle Schedule 129 (8/2001)

This form is to be used in conjunction with the following ACORD forms to individually schedule vehicles: ACORD 127 - Business Auto Section ACORD 128 - Garage and Dealers Section ACORD 132 - Truckers/Motor Carriers Section ACORD 143 - Transportation Section Within the Remarks section of the above forms, a note should be made to "see attached vehicle schedule." IDENTIFICATION SECTION Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.

Date Month/day/year on which the form is completed. Producer Producer's name, address and telephone number. Phone (A/C, No, Ext) Producer's telephone number. Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. Subcode If the agency uses a subcode identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Applicant (First Named Insured) First Named Insured as it appears on the ACORD 125. Effective Date Enter the Effective date on which the terms and conditions of the policy will commence. Expiration Date Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). Audit Use this field to indicate the audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other VEHICLE DESCRIPTION This section is used to collect pertinent information on the vehicles that are to be insured, including what they are, how they are used and what coverage applies to them. Veh # Number assigned by the agent to this vehicle for purposes of tracking in the application process. Year Vehicle's model year. Make Vehicle's manufacturer (e.g., Buick). Model Manufacturer's model name (e.g., Regal). Body Type Vehicle's body type (e.g., 4 door sedan).

Vehicle Type Check the appropriate box. PP (private passenger), SPEC (special), or COML (commercial). V.I.N. Full vehicle identification number assigned by the manufacturer. Sym/Age Enter the age of the vehicle in years, as follows: · 1-Current model year · 2-First preceding model year · 3-Second preceding model year · 4-Third preceding model year · 5-Fourth preceding model year · 6-All other autos Cost New If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and equipment. City, State, Zip where garaged List the location where this vehicle is normally garaged. Lic State Enter the state in which the vehicle is licensed. Territory Enter the rating territory in which the vehicle is principally garaged. GVW/GCW These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly. GVW Gross Vehicle Weight. Maximum loaded weight for which a single vehicle is designed by the manufacturer. GCW Gross Combined Weight. Maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which the truck-tractor is designed as specified by the manufacturer. Class This is the primary industry classification code found in rating manuals for commercial vehicles as determined by: · If this is a fleet or non-fleet policy · Commercial autos by size, business use, radius of operation and whether truck or · trailer type · Public autos by type of vehicle, radius or seating capacity S.I.C. This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. Factor This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you are not rating this application. Seating Capacity Used for public vehicles and livery vehicles. Enter the number of passenger seats available. Radius Enter the appropriate radius code as follows: L - Local . . . . . . . . . . . . . . . . . . . . Up to 50 miles. Not frequently operated beyond a 50- mile radius from the point of principal garaging. I -Intermediate . . . . . . . . . . . . . . .Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the

point of principal garaging. LD - Long Distance . . . . . . . . . . Regularly and frequently operated beyond a radius of 200 miles. Farthest Term For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of this vehicle, that this vehicle travels to. Drive to Work/School If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are: · Drive to Work or School under 15 miles one way · Drive to Work or School 15 miles or over one way Use Check the appropriate box for the primary usage of this vehicle. Options are: · Pleasure-Private passenger vehicles or pickups/vans not used for business · purposes · Farm/Private passenger vehicles or pickups/vans principally garaged and used on · a farm or ranch · Retail-Pick up or delivery of property to individual households · Service-Transportation of personnel, tools, equipment or supplies to or from a · job site · Commercial-Transportation of property in vehicles other than those defined as service or retail Check Coverages Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the symbols indicated in the coverage section of ACORD 137. Abbreviations are: Liab . . . . . . . . . . . . . . . . . . . . . . . . . . . Liability No-Fault . . . . . . . . . . . . . . . . . . . . . . ."No-Fault" coverage available in the state Add'l No-Fault . . . . . . . . . . . . . . . . . Additional "No-Fault" coverage available in the state Med Pay . . . . . . . . . . . . . . . . . . . . . . Medical Payments Uninsd. Mot . . . . . . . . . . . . . . . . . . . Uninsured Motorist Underins Mot.. . . . . . . . . . . . . . . . . . Underinsured Motorist Tow & Labor. . . . . . . . . . . . . . . . . . . Towing and Labor Spec C of L . . . . . . . . . . . . . . . . . . . . Specified Cause of Loss F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Specified Cause of Loss of Fire F & T. . . . . . . . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss of Fire and Theft F, T, & W . . . . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss of Fire, Theft and Windstorm LSP . . . . . . . . . . . . . . . . . . . . . . . . . . . .Limited Specified Perils Comp. . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive Coverage Coll. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Collision Coverage Deductibles Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt - Stated Amount basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if the other than collision deductible is for comprehensive coverage or some sort of specified cause of loss coverage, along with listing that deductible amount. Enter the collision deductible in the space provided. Net Veh Dr/Cr Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under Remarks a description of each debit or credit used in the calculation of the net rating factor. Tot Prem Enter the total premium for the vehicle.

Watercraft Application 82 (2/2001)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Watercraft Application. This form can be used either as a stand-alone application or as a supplement to the Homeowners Application (ACORD 80) if physical damage on watercraft is being written under the Homeowners policy. Check with the company to determine whether physical damage can be written on the Homeowners policy. If coverage will be provided under a yacht policy, do not use this form. Use ACORD 210, Yacht Section. The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website, this information appears under the title PERSONAL LINES GENERIC SECTIONS. BOAT HULL Provide hull number if more than one hull is to be insured. Power Indicate the method of propulsion. Sailboats can be powered by an auxiliary engine, therefore, please check SAIL in addition to the auxiliary type of propulsion for sailboats. Type of Hull Indicate the type of watercraft to be insured. "Personal WC" refers to "personal watercraft". Hull Material If the hull material is not fiberglass, metal or wood, please indicate the material type in the remarks area. Hull Design Indicate the type of hull to be insured. Fuel Tank Indicate whether the fuel tank is made of fiberglass or metal. Year Model year of the unit in YYYY format. If built at home, enter the year built. Manufacturer/Model Name of the manufacturer and the model (e.g., Chris Craft Tournament Fisherman, Pacemaker Runabout). Length Overall length measured in feet from bow to stern. Max Speed Enter the maximum speed of the craft. State if measured in knots or miles per hour. Date Purchased Date the watercraft was purchased by the insured in MMYY format. Cost New Cost of the boat when it was purchased new, in whole dollar amounts. Present Value Boat's present value, stated or agreed, in whole dollar amounts. Name of Boat Name in which the watercraft is registered. Registration Number/Hull Identification Number Enter the registration number and the serial number of the watercraft. Waters Navigated Identify the primary area of operation (e.g., San Francisco Bay Area, Hudson River). Territory This is typically the navigation territory. However, use company manuals to determine territory. Berth/Storage Location Physical address where the boat is stored; no P.O. boxes.

Lay-Up Period Specify the period when the boat is not in operation (e.g., October through March). Also, state if the boat is stored afloat or in a dry dock. If the boat is stored afloat, indicate the devices used to prevent ice damage (e.g., bubble system). ENGINE/MOTOR Use this section to provide information about all engines and motors used to propel the boat. Year Model year of the engine/outboard motor in YYYY format. Manufacturer/Model/Serial Number Enter the name of the manufacturer, the model (e.g., Mercury Mark 50, Evinrude 200), and the serial number. Horsepower Enter the horsepower. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in the space labeled "other". Fuel Indicate the fuel used to power the engine. For Outboard Motors Only Provide the date purchased, cost when new and present value. TRAILER If boat trailer insurance is to be included on the watercraft policy (usually only available for stand-alone watercraft policies), enter all pertinent information regarding the boat trailer: year, manufacturer, serial number, number of axles, capacity, date purchased, cost. COVERAGES/LIMITS OF LIABILITY Indicate the limit of insurance, deductible and coverage premium for each applicable coverage. List any additional coverages, including their limit and premium in the other coverage section. Hull Amount of coverage for boat damage; this may include collision liability. Outboard Motor Amount of coverage for damage to the outboard motor. Limits may be entered for three motors. * Coverage for inboard motors is included in the hull coverage. Portable Accessories Coverage amount for those items not permanently attached to the boat. Examples: · Oars · Anchors · Life Preservers · Fire extinguishers Trailer Amount of coverage for damage to the trailer. Liability Coverage amount for bodily injury and property damage. May be called protection and indemnity. Medical Payments Amount of coverage for medical expenses for bodily injury to occupants of the boat. Uninsured Boaters Liability Coverage amount for bodily injury caused by an uninsured boat operator. Some companies offer this coverage. Credit Total credit amount for the watercraft portion of the policy. Total Estimated total premium. Describe all Credits to Apply to each Boat

List all credit amounts and names for each boat. PAYMENT PLAN Indicate whether the agency or the company(direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment. ADDITIONAL INTEREST Provide the following information for each entity having an interest in the motors or the watercraft to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the lienholder (e.g., bank in which the loan is held) or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number. RATING/UNDERWRITING Provide a description of the equipment on the boat that is of particular interest to the underwriter. Indicate the number present on the boat and an appropriate description of each piece of equipment. Bilge Pumps A bilge pump is a manually operated or automatically activated device used for pumping water from the inner part of the ship's hull. Using the same principle as the manual pump, the automatic pump is activated by the rise of water within the hull. Specify the manufacturer and the model (e.g., Dynaflow Pump 304). Cooking Stove Indicate the manufacturer, model and fuel type. Also indicate if there is more than one stove. Fume Detector A device used for detecting the presence of fuel vapors below deck. Specify the manufacturer and model (e.g., Sniffer 203). CO2/Chemical System A built-in fire extinguishing device. Indicate if it is manual or automatic and identify the spaces protected. Include the manufacturer and model. Use the Remarks section if necessary. Fire Extinguishers Indicate the number of fire extinguishers on the boat. Specify the type, size, and the date last weighed, if available. Depth Sounder An electronic device for determining the depth of the water beneath the boat. Indicate the manufacturer and model (e.g., Moran 6" - 150/SV-300). Radar A device for detecting distant objects and determining their position. Specify the manufacturer and model. Radio Direction Finder A navigational aid employing a radio signal. Enter the manufacturer and model (e.g., Loran, GSP). Ship to Shore Radio Indicate the type of radio. Examples: · SSB-Single Side Band · VHF-FM-Very High Frequency - Frequency Modulation · CB -Citizens Band · Cellular Phones · Marine Radio Anti-Theft Devices Special locks, burglar alarms or engine cut-out devices may be employed by the applicant. Marina security may be noted as well. Heating Describe heating system, if any. Other Use the blank spaces to list additional equipment. Attach a separate list if necessary. PORTABLE ACCESSORIES List the portable accessories that are to be insured.

Include the name of the equipment, year of manufacture, name of manufacturer, and the model and serial number if applicable. Also provide the limit(s) of insurance required. OPERATORS List the name, sex, marital status (S-Single, M-Married, D-Divorced, SEP-Separated, W-Widowed), date of birth (MM/DD/YY), social security #, auto drivers license number and licensed state if applicable, for each household member and any other frequent operators. OPERATORS EXPERIENCE Indicate if any operator completed courses offered by the United States Coast Guard Auxiliary, the Power Squadron or other recognized training. The underwriter will also be interested in the number of years of boating experience and the type of boats operated or owned. Some companies require the percentage of use for each operator. Be sure to crossreference the operator number. HULL INFORMATION Use the Remarks section to provide additional information for any questions answered with a "Yes" response. 1. Is the boat chartered to others? If the vessel is chartered, describe the type of arrangements, destination, length of time and frequency. Indicate if it is a bare boat charter where no crew or supervision is furnished, a voyage charter, a time charter, etc. Include the purpose of the charter (sight-seeing, fishing) and whether alcohol is served. 2. Is the boat used commercially or for business purposes? Describe the commercial or business use of the vessel. Indicate if the vessel is used for demonstrations, promotions, fishing, sight-seeing trips, etc. 3. Is the boat used for racing? If the vessel is used for racing, indicate the frequency of such races during the year, the extent of the race, the waters navigated, etc. 4. Is the boat used for waterskiing? Indicate how frequently the vessel is used for waterskiing. 5. Does the applicant employ a paid crew? Specify the number of crew members, and whether they are full or part time. Be sure to list the crew members in the Operator section of the application. 6. Any sleeping facilities? Provide number of beds. 7. Any existing damage to the boat? If yes, describe in detail. GENERAL INFORMATION Use the Remarks section to provide additional information for any question answered with a "yes" response. 1. Has the applicant lived at current address for less than 3 years? Indicate the previous address of the applicant. 2. Any operator have physical/mental impairment? Answer "yes" only if the impairment impedes the use of the watercraft. Indicate the impairment and any applicable medical treatment being used. 3.Any drivers license suspended/revoked during the last 3 years? Indicate if the drivers license of any operator was suspended or revoked and explain the circumstances. 4. Has any operator had an accident/conviction during the last 3 years? Indicate accidents/convictions for both driving and boating records. 5. Any other insurance with this company? Indicate if other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the remarks section along with any policy numbers available. 6. Any losses occur during the last 3 years? Describe in detail, all losses during the last three years. Include data on the operator, the type of loss, the amount of the loss, the date and the disposition.

7. Any coverage declined, cancelled, or non-renewed? Provide the circumstances surrounding this situation. This question cannot be asked in Missouri. 8. During the last five years(ten in RI), has any applicant been convicted of any degree of the crime of arson? In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.

Workers Comp First Report of Injury or Illness 4 (2/2001)

ACORD, in conjunction with the IAIABC (International Association of Industrial Accident Boards & Commissions) developed this standard First Report. The form tracks with the IAIABC and ANSI X12 EDI standard for reporting Workers Compensation losses. The form is designed as a first notice of a claim for injury or illness by an employee. In nearly all cases, the form is completed by the employer and sent directly to the insurer or the state workers compensation board. It contains information about the employer, insurance carrier, employee, the occurrence leading to the injury or illness, and the nature of injury or illness. Instructions to the employer regarding completion of the form are contained on the third and fourth pages of the form. Each jurisdiction mandates the form to be used within that state. The new version of ACORD 4 is accepted in many jurisdictions. It is anticipated that this number will continue to increase significantly as states adopt the IAIABC and ANSI X12 EDI Standard. As of November 1, 1998, the following states are reported to accept ACORD 4. Consult your company about use in other states. Connecticut Florida Idaho Illinois Maryland Mississippi New Mexico Ohio Rhode Island South Carolina. In addition, Wisconsin accepts ACORD 4WI, Wisconsin Employer's First Report of Injury or Illness.

Workers Compensation Application 130 (8/2000)

ACORD's Workers Compensation Application is a self-contained Commercial Lines application that does not require the completion of the Applicant Information Section (ACORD 125). Therefore, complete the entire Identification section of this form. The Workers Compensation Application provides for workers' compensation, employer's liability, and voluntary compensation coverages. The Policy Information and Rating Information sections have been designed to follow workers' compensation rules published by the National Council on Compensation Insurance (NCCI). Other plans may be used with this form as well. Please refer to the NCCI manual for coverage definitions. This form may not be used in Florida. Refer to Florida Workers Compensation Application, ACORD 130 FL, in the State Forms section of this guide. IDENTIFICATION Date Month/day/year in which the form is completed. Producer Producer's name, address and telephone number. Code Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.

Phone (A/C, no., ext.) Telephone number where the producer may be reached. Subcode If your agency uses a sub-code identification system with the company, enter the appropriate code. Agency Customer ID Customer's identification number assigned by the agency. Company Name of the applicable insurance company. Use the actual name of the company within the group in which you wish to have the policy issued. Do not use group names. Underwriter Field used to direct the application to a specific company underwriter by name. Applicant Name Full name of the applicant as it appears on the policy. (The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, the one intended to receive these rights and responsibilities is named first.) If joint ownership is claimed, the name used may include both names (e.g., John and Mary Smith). Phrases such as "et al." or "As their interests may appear" are not legal entities and therefore unacceptable. Mailing Address Address at which the First Named Insured is to receive all mail. Years in Business Number of years the applicant has been in business. SIC Appropriate Standard Industry Class code assigned to the particular type of business (if known). Form of Business Organization Identify the applicant as an Individual, Partnership, Corporation, Sub Chapter "S" Corporation, Limited Corporation, or Other. If Other, provide a description (e.g., Professional Association). If there is more than one Named Insured, list each along with its form of organization (e.g., The Green Thumb Co., a corporation, John Jones and Bill Smith, a partnership; or A joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.). Federal Employer ID Number FEIN is assigned by the IRS to specifically identify the applicant and is required in most states before a policy can be issued. A separate FEIN may apply to each entity named as an insured. For individuals with no FEIN, use Social Security Number. NCCI ID Number A nine-digit number assigned to the applicant by the National Council on Compensation Insurance (NCCI). This number is required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks occurring in more than one state. Other Rating Bureau ID or State Employer Registration Number A state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an independent bureau state. In Minnesota, use this box to record the applicant's unemployment account number, as required by the state. In New Jersey, use this box to record the applicant's state employer registration number. SUBMISSION STATUS Use the Quote/Issue Policy/Bound boxes to indicate whether the response to this application from the company is expected to be a quote or an issued policy. Also indicate if the risk is bound. Include the date coverage began and attach a copy of the binder. This application is not a substitute for a binder. You may check more than one box (e.g., if the underwriter indicated by telephone that the risk is acceptable and coverage can be bound, check both Bound and Issue). For Assigned Risk business check the "Assigned Risk" box and complete an ACORD 133 Workers Compensation Insurance Plan Assigned Risk Section. Rules for binding assigned risk policies apply. The Quote, Issue Policy and Bound options do not apply when submitting an assigned risk application. Please refer to the instructions for the ACORD 133 for specific uses of the ACORD 130 elements as they apply to assigned risk business. BILLING/AUDIT INFORMATION Billing Plan Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. For the Other option, use the company's specific designation for the plan being used (e.g., Bi-monthly or 40-30-30). % Down For bound policies, list the percentage of the total estimated annual premium that has been (or will be) received as a down payment.

Audit Indicate the frequency with which audits should be undertaken for this policy. LOCATIONS List all usual workplaces of the applicant including the physical address, not post office boxes. POLICY INFORMATION Proposed Policy Eff Date Date on which the terms and conditions of the policy will commence. For assigned risk business being submitted with the ACORD 133 use the effective date on that form, following state mandated rules. Proposed Exp.date Date on which the terms and conditions of the policy will expire. The normal policy period (effective date to expiration date) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term, to concur with other policies. Normal Anniversary Rating Date Normally, the rates used are in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled or short-termed polices, enter the original effective date. Participating/Non-Participating A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating basis. Check with your company on the availability of plans. Retro Plan Retrospective Rating Plans Permits the adjustment of the final premium based on the actual premiums and losses of the applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check with your company on the availability of plans. Part 1 (States) States in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states where the applicant has operations. Part 2 - Employers Liability Requested limits for Part 2 of the policy (Employers Liability Insurance). The basic limits of liability under Part 2 are: Bodily Injury By Accident - $100,000 per accident; Bodily Injury by Disease - $500,000-policy limit; Bodily Injury by Disease $100,000 per employee. Express limits with full dollar amount (all zeros shown) on the application. Part 3 - Other States Insurance Indicate the states in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the potential for operations during the policy term, but none currently exists as of the effective date of the policy. Deductibles If a deductible option exists in the state where coverage is being applied for check the appropriate deductible type. (In Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.) Amount/% Indicate the amount of the deductible as a whole dollar amount or as a percentage. For percentages indicate the percentage amount followed by the percent (%) sign. Other Coverages Use this space to request optional United States Longshoremen's & Harbor Worker's (USL&H) coverage and Voluntary Compensation coverages. Exposures for these optional coverages as well as additional coverages should be described in the Specify Additional Coverages/Endorsements section. Dividend Plan or Safety Group Identify the specific plan or safety group of which the applicant is a member. This field is related to the participating plan. Check with your company on the availability of plans. Additional Company Information Any additional company or state specific information should also be listed in this section. RATING INFORMATION Information in the Rating section must be entered by state and location. If there are multiple named insureds, information must be shown by individual entity.

State State abbreviation for the associated location. LOC Location Number for each entry corresponding to the locations listed in the Locations section above. Class Code Code which best describes the applicant's business. Remember that it is the business of the employer, not the individual employees, that is being classified. Consult the proper rating manual to determine the code. Rating bureaus may exercise control over classification assignment. Company Use Leave blank. The insurer may use this space for special computer codes to identify the applicable class description wording. Categories, Duties, Classifications Single class code may include several related descriptions of activities/operations. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid mis-classifying the operations. No. of Employees, Full Time/Part Time Number of employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. Show full time and part time employees separately. Estimated Annual Remuneration Total annual payroll for the class. Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium. Rate Manual Rate for the classification from the appropriate state manual. Estimated Annual Premium The rate is applied (multiplied) to every $100 of remuneration (payroll) and the result is the Estimated Annual Premium for this classification. Additional Coverages/Endorsements Explain the applicant's exposures and payroll for any other coverage requested, including USL&H and Voluntary Compensation. RATING COLUMNS Rating Worksheet The Factor and Factored Premium columns are used to calculate the total estimated annual premium. Agents completing the rating process should fill out this section of the application or attach a rating worksheet. Total Add the amounts for each class to obtain the total estimated pre-modified premium. Increased Limits Enter the factor and modified total premium if limits other than the standard limits for Part 2 Employers Liability are requested. Deductible If a state deductible option is available and chosen, enter the deductible factor and the modified total premium. Experience Modification If the applicant is subject to experience rating, enter the experience modification factor and the modified total premium. Generally the business has to have been in operation for at least two years under present ownership and the premium must meet or exceed a level which is established by the state to qualify for experience rating. If more than one modification factor applies to the applicant, explain in the Specify Additional Coverages/Endorsements section. Attach the most recent experience rating data sheet. Loss Constant If a Loss Constant is applicable due to low premium levels enter the flat amount as per the rating manuals. Assigned Risk Surcharge Applicable only to assigned risk accounts. A state specific surcharge for placement of business into an assigned risk pool. ARAP Assigned Risk Adjustment Program A state specific adjustment for Assigned Risk policies. Premium Discount If a Premium discount is applicable due to large premium levels, enter the discount rate and the modified total premium.

Expense Constant Enter the flat amount of the expense constant as applicable per state rating manual. Optional Lines If any optional factors, charges or credits are required such as a state tax enter the option title, factor (if applicable) and adjustment amounts in these available spaces. Total Estimated Annual Premium Amount resulting from applying all modifications, discounts, taxes and other rating criteria to the total estimated premodified premium. Minimum Premium Found on state rate sheets opposite the class code; they apply by policy. If two or more classifications with different Minimum Premiums are included on one policy, the highest usually applies. Check the appropriate rate manual. Deposit Premium Dollar amount due the insurer at inception. INDIVIDUALS INCLUDED/EXCLUDED Based on state laws, certain positions within an organization, such as sole proprietors and partners, may not be covered by the applicable workers' compensation law, and may elect to be brought under such law. Conversely, executive officers of corporations are usually considered to be employees, but may elect to be excluded from coverage. Refer to the NCCI or applicable state workers' compensation manual for specific state details. Since the inclusion or exclusion affects coverage and premium, this section must be fully completed. Name Partner, executive officer or relative to indicate whether or not the individual is to be covered by the policy. Date of Birth Individual's birthdate. Title/Relationship Either the individual's title within the organization or relationship to the organization's owners. Ownership % Percentage of ownership the individual has in the organization, if applicable. Duties Briefly identify the duties of the individual. Inc/Exc Indicate if the individual is to be Included or Excluded under the policy's coverages. Class Code For individuals to be included based on the duties described above. Remuneration Estimated annual Remuneration for individuals to be included. Minimum or Maximum remunerations may apply based on state laws. (Enter the class code and remuneration in the Rating Information section of the application for all included individuals). PRIOR CARRIER INFORMATION/LOSS HISTORY Either this section should be completed or a loss history report attached covering the last five years. If a loss history report is attached, check the appropriate box. Year Year or policy period. The most recent policy period should be listed first. Carrier & Policy Number Carrier's name and policy number for the corresponding policy. Annual Premium For the corresponding policy. Use the final audited premium when available. Mod. If the risk was subject to experience rating, enter the Experience Modification in this column for the corresponding policy. # Claims Total number of Claims for the corresponding policy term. Amount Paid The total dollar amount actually paid for all open or closed claims. Reserve Enter the amount in Reserve for any open claims, with the valuation date of the reserves. Estimates are acceptable; enter

zero if none. NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS This section informs the underwriter of each applicant's business and the way it is conducted by premises. Operations, which may not be apparent in a general description, may be segmented by location. For example, location #1 may be the general offices while location #2 may be the warehouse. The section should include enough detail to enable the underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial Lines Manual or Workers' Compensation Manual, because they do not provide adequate detail. For example, a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg.N.O.C." If the applicant is a manufacturer, describe the: Raw materials used Process of work performed Products manufactured; who uses them and how they are used If the applicant is a contractor, describe the: Type of contractor Work performed Specialized equipment used Nature of sub-contracts If the applicant is a merchant, describe the: Type of operation, wholesale or retail (if both, give the percentage of each) Merchandise sold; indicate if it is domestic or foreign product Services provided Whether or not the applicant delivers If the applicant is a service organization, describe the: Type of service performed Location The applicant's clients (e.g., general public, dentists, banks) GENERAL INFORMATION Use the Remarks section to provide additional information for any questions answered "Yes". 1. Does applicant own, operate or lease aircraft/watercraft? Describe any aircraft exposure excluding commercially scheduled flights. Name any employee who is a licensed pilot. Explain his or her duties and describe the type of license. Describe any watercraft which is owned, leased or operated, and explain its use. 2. Do operations involve storing, treating, discharging, applying, disposing or transporting of hazardous material? (E.g., landfills, asbestos, wastes, fuel tanks, etc.) Explain the exposure and the precautionary measures implemented to handle hazardous materials. Exposures include: flammables, explosives, radioactivity, caustics or fumes and their storage, disposal or transportation, or any other material with a known occupational disease exposure. 3. Any work performed underground or above 15 feet? Detail the frequency and nature of such work, and the number of people involved. 4. Any work performed on barges, vessels, docks or bridge over water? Describe any work on barges, vessels or docks and the location, frequency and number of people involved. 5. Is applicant engaged in any other type of business? List all other businesses and the carrier for that business's workers' compensation coverage. 6. Are subcontractors used? Explain the nature and frequency of any subcontracted work. Give the percent of work subcontracted. Are Certificates of Insurance required? 7. Any work sublet without certificates of ins. Describe the nature and frequency of the subcontracted work and indicate if the classifications and remuneration for such work have been included in the Rating Information section. 8. Is a formal safety program in operation? Describe the safety program. Does it involve meetings, classes or incentives? 9. Any group transportation provided? Is a van pool program in effect? Does the employer shuttle employees to job sites? What type of conveyance is used? How many employees are transported? How often? Over what distance? 10. Any employees under 16 or over 60 years of age? Specify the number of employees in each category and the duties they perform.

11. Any seasonal employees? How many employees? How many hours do they work? At what time of the year are they employed? What are their duties? 12. Is there any volunteer or donated labor? Explain the circumstances under which volunteer labor is used and the nature of the work. 13. Any employees with physical handicaps? Describe the nature of the work and explain the circumstances under which physically handicapped workers are employed. Indicate the number of employees and the type of handicaps. Is the applicant involved in a special community program for handicapped people? If eligible, has the employee been registered in a second injury fund? 14. Do employees travel out of state? Describe the nature of the travel and indicate the number of employees, frequency and mode of transportation. 15. Are athletic teams sponsored? Describe the nature of the athletic activities and indicate the number of employees involved (if any). Indicate whether the applicant provides an accident and health policy to cover athletic activities. This may include company, school or community teams or leagues, such as Little League. 16. Are physicals required after offers of employment are made? Are employees required to undergo a physical examination after they have been made an offer for employment? Describe the extent of the physical examination and indicate which applicants are required to take them. 17. Any other insurance with this insurer? If other insurance policies of any kind are in force with this insurer, identify the coverages, policy numbers and terms. You may also note other submissions for this account being considered. 18. Any prior coverage declined/cancelled/non-renewed (last 3 yrs.)? The fact that such action occurred is not as important as the reason for the action. Provide all details. 19. Are Employee health plans provided? Indicate the carrier name and policy number for the health plan. 20. Is there a labor interchange with any other business/subsidiary? Indicate who the interchange is being done with and their relationship to the insured. 21. Do you lease employees to or from other employers ? For leasing employees indicate who you are leasing them to. For leased employees indicate who you are leasing them from and if you have a certificate of insurance from the lessor. 22. Do any employees predominantly work at home? Indicate who works at home and what their hours of operation are. CONTACT INFORMATION Inspection (Phone and Name) Enter the name and telephone number of the contact person who will assist the insurer in conducting a physical inspection survey. Accounting Records (Phone and Name) The insurer may need to contact the applicant for audit purposes. Provide the name and telephone number of the individual responsible for such records. Claims Information (Phone and Name) Provide the telephone number and name of the person the insurer is to contact regarding any potential claims inquiries. Remarks Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.

Young Driver Questionnaire 93 (2/95)

This form is generally completed by drivers under the age of twenty five. The Young Driver Questionnaire provides additional underwriting information that is usually common to youthful drivers. This form should be completed and signed exclusively by the young driver with no input from the parents and/or agent.

Personal Auto Policy Change Request 71 (6/2001)

Use this form to request mid-term changes to any personal auto policy. The form should be used instead of individual turnaround endorsement requests. A copy of the request may be sent to the insured to confirm that the change is submitted to the company. The generic fields on this form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website (www.acord.org),, this information appears under the title PERSONAL LINES GENERIC SECTIONS. For changes to property, mobile home, inland marine, watercraft and umbrella coverages, use ACORD 70, Personal Policy Change Request (Except Auto). 229 IDENTIFICATION This section provides essential producer, company and insured information. It should be fully completed for all types of changes. A copy of the policy's declaration page can be attached to provide additional identification information. All data fields in this section, except the insured's name and mailing address, should contain existing policy information -- not changed data. * Most sections begin with a change indicator. Enter either an A-Add, C-Change, D-Delete, or check the appropriate box. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). VEHICLE DESCRIPTION/USE If the request pertains to change of vehicle information, complete this section. The form permits three vehicle modifications. Obtain information directly from the policy or vehicle registration when possible. Vehicles include automobiles, motorcycles, vans, recreational vehicles, motor homes, trailers and pickups. Indicate the type of change being requested. When adding a vehicle, the entire description section should be completed to assist the company in processing the request. Also complete questions 1-5 of the General Information section and at least the comprehensive and collision portion of the Coverage section. Use the Remarks section for any additional information required by the company. When requesting a change, enter only the information being changed. All other items on the policy will remain the same. If deleting an item, provide adequate information to process the request and indicate the reason for the deletion in the Remarks section. Veh # The current vehicle number, before renumbering. Year Model year of the vehicle. Make, Model and Body Type Manufacturer's trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4 door sedan). VIN/Registered State Full vehicle identification number appearing on the title certificate or registration. Enter the state where the vehicle is registered. If the vehicle is registered in a state other than where it is garaged, explain in the Remarks area. HP/CC Amount of horsepower or the number of cubic centimeters of displacement. DATE LEASED Year the applicant leased the vehicle in the YYYY format. Date Purch Year the applicant acquired the vehicle in YYYY format. New/Used Mark "N" if the applicant bought the vehicle new or "U" if the vehicle was used.

Cost New Original cost of the vehicle. Symbol Age Grp If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual. Terr Rating territory code where the vehicle is principally garaged. Refer to rating manual. Mile 1 Way Wk/Schl Number of miles from the garage location to school or work. # Days Week Number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station. # Weeks/Mo. Number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station. Usage Pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation, profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of occupation, profession or business is considered pleasure. Perform Vehicle's performance level. Indicate High (H), Intermediate (I) or Sport (S). Multi-Car Check box only if multi-car credit applies. Car Pool Indicate if any vehicle is used in a car pool for travel to work or school. Garaged Indicate if the vehicle is parked in a garage at night. If the vehicle is left on the street, at school or some other equally exposed place, provide this information in Remarks section. Examples of exposures are: · Off street (driveway) · Off street (at school) · Street (at school) · Street (at residence) Odometer Reading Current number of miles on the odometer. Annual Mileage Total estimated annual mileage for each vehicle. Govern Driver Driver assigned to each vehicle for rating purposes. Driver Use % Percentage that each driver uses each vehicle. Usage for each vehicle should total 100 percent. Class Rate classification for each vehicle. Refer to manual. Some companies determine class automatically from information provided in Vehicle Use and Driver Information sections. Seat Belt Check box if the vehicle is equipped with automatic seat belts. Air Bag Indicate D for driver side air bag; B for vehicle equipped with air bags for both driver and front passenger. Anti - Lock Brakes 2/4 For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4- wheel anti-lock braking system. Anti - Theft Devices If vehicle is equipped with an anti-theft device, indicate the type.

Credits and Surcharges Any other credits and/or surcharges that will apply to any vehicles. GARAGE LOCATION Indicate the vehicle number and the complete address including the ZIP code for any vehicle not kept at the mailing address. Provide this information if the mailing address is a P.O. box or rural route address, or when a driver is at school with one of the vehicles. VEHICLE COVERAGE/PREMIUMS For each automobile to be added or changed, enter the vehicle number, year and make on the first row of the Vehicle Coverage/Premium section. If the vehicle is added, enter all applicable coverage information. If coverages on an existing vehicle are to be added, changed and/or deleted, enter only coverage information that is different. Single Limit Liability (CSL) Desired limit of both bodily injury and property damage. If an entry is made in this field, leave blank the separate Bodily Injury and Property Damage fields. Show a property damage deductible, if applicable. Bodily Injury Liability Desired per person and per accident limits. Property Damage Liability Desired limit. Include a property damage deductible, if applicable. No Fault Coverages Refer to the applicable state manual for no fault/personal injury protection coverages. Each state where these coverages are available has a unique mandatory coverage and unique coverage options. Space is provided here to list both mandatory and optional coverages. Medical Payments Desired per person limit. Uninsured Motorist Bodily injury (per person and per accident) and property damage (per accident) limits. Circle CSL and enter the limit in the per accident area for combined single limits. Many companies require supplemental uninsured motorists applications. Include them when submitting this application. Underinsured Motorist Bodily injury (per person and per accident) and the property damage (per accident) limits. Circle CSL and enter the limit in the per accident area for combined single limits. Many companies require supplemental underinsured motorist applications. Include them when submitting this application. Comprehensive Comprehensive coverage deductible for each vehicle. Enter stated amount, if other than actual cash value (ACV), in the space to the right and indicate the vehicle to which it applies. Collision Collision coverage deductible for each vehicle. If stated amount applies for the type of vehicle being insured, enter the amount in the space to the right and indicate the vehicle to which it applies. Towing & Labor Amount per disablement for each vehicle, if applicable. Some companies provide a verbal limit. Consult company manuals for cases in which a verbal limit applies. Transportation Expense/Rental Reimbursement Amount desired, per day limit and maximum amount. Additional miscellaneous coverages can be included in the blank spaces, or in the Remarks Section. GENERAL INFORMATION Complete this section if a vehicle or driver is being added to the policy. Questions 1-5 pertain to addition of a vehicle. Questions 6-10 refer to addition of a driver to the policy. Answer only questions pertinent to the change being requested. If there are any "Yes" responses, explain completely in the Remarks section. Use an additional sheet of paper if space in the Remarks section is inadequate. 1. Excluding any encumbrances, are any vehicles not solely owned by and registered to the applicant? Show the vehicle number and name of the vehicle registrant if not the applicant.

2. Any car modified/special equipment? Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any customized painting such as murals or pin striping; any equipment installed to overcome a physical handicap. Indicate vehicle number and describe modifications and the cost of the special equipment. 3. Any existing damage to vehicle, including damaged glass? Indicate if any vehicle has been damaged and unrepaired as of the application date. Indicate the vehicle number and completely describe the damage. 4. Any car kept at school? Identify the household member and name and location of the school. Include the distance between the school and the residence garage location. 5. Any car parked on street? Determine if any vehicle is parked on the street or otherwise kept outside an enclosed garage when not in use. (Indicate vehicle number from the vehicle description area indicating where the vehicle is parked.) 6. Any household member in military service? Detail branch of service, rank and location of base for any household member in active military service. Determine if any vehicle is located at the military location. 7. Any driver's license been suspended/revoked? Indicate the driver number, period of suspension, reason for suspension, and date the license was reinstated. 8. Any driver have physical/mental impairment? List any operator with a physical or mental impairment which could hinder the safe operation of a vehicle (e.g., amputation, epilepsy). If impaired, enter the name of the driver, describe any special equipment installed and treatment or medication being administered. 9. Any financial responsibility filing? Indicate the driver's name, reason for the filing and date of original filing. 10. Any coverage declined, cancelled, or non-renewed during the last three years? Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within the last three years. List the person's name and why the action was taken. This question cannot be asked in Missouri. DRIVER INFORMATION When adding a driver, complete this entire section, questions 6-10 of the General Information section and the entire Accidents/Convictions section. Refer to the driver's license for the licensed operator being added to the policy. If more space is required, use the Remarks section. If a change is made, enter only the information being changed. If a driver is being deleted, provide sufficient information to identify and process the request. Indicate reason for the deletion in the Remarks section. Driver # Indicate the current driver number, before renumbering. Name Name of the licensed operator appearing on the driver's license. Enter the surname only if it differs from the insured's. Sex F for female, M for male. Mar Stat Marital status of the driver. Examples: S . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . .. Divorced SP . . . . . . . . . . . . . . . . . . . . . . .Separated W. . . . . . . . . . . . . . . . . . . . . . . . Widowed. Relation to Applicant Driver's relationship to the insured. Examples: I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insured

S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spouse C . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child SIB. . . . . . . . . . . . . . . . . . . . . . . . . . . Brother/Sister P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent E . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employee. Date of Birth Birth date of the driver (e.g., March 7, 1944 should be 3/7/44). Occupation Occupation of the driver. Date Lic Date (MM/YY) the driver was permanently licensed. Stdt >> 100 Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address. Good Stdt Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies. Drv Train Indicate if driver training credit applies to the driver, if required by the company. Refer to the company's manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit. ACC Prev Cse Date Date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies. Drivers License #/Licensed State Complete driver's license number and licensed state for the licensed operator. Copy directly from license if possible. Social Security # Driver's social security number. ACCIDENTS/CONVICTIONS Complete this section only if any driver being added to the policy has had an accident, been convicted of a violation or had a comprehensive loss. The number of years this information should cover must be in accordance with the company's and state's requirements. If there have not been any accidents, convictions or comprehensive losses during the indicated time period, enter "None". This section must be completed fully and accurately. Many companies verify driving records with state motor vehicle departments. Discrepancies between the application and the report may result in processing delays and unnecessary correspondence with the company. Date of Accident/Conviction Date the accident or conviction occurred. Description of Accident or Conviction Complete description of the accident or conviction including the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgement of guilty, plea of nolo contendere or forfeiture of bail. Use Remarks section or an additional piece of paper if necessary. Place of Accident/Conviction City and state of the accident or conviction. BI or Death Indicate whether bodily injury or death occurred. Fully describe the accident. Amount of Property Damage Total amount of property damage (applicant's and all claimants' combined damages). Refer to company manual. ADDITIONAL INTEREST Indicate if Additional Interest (additional insured-lessor, certificate holder) or Loss Payee. Show complete name and mailing address. This section is often used to delete a lienholder from a policy after the loan is repaid.

PRODUCER'S SIGNATURE / INSURED'S SIGNATURE Space is provided for signatures of the producer and/or the insured. Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are made that are considered significant to the company. Refer to your company rules. Many companies, or state laws require the insured's signature when auto, liability, no fault, or uninsured motorists coverage is changed or deleted. Refer to your company or state rules.

Personal Policy Change Request 70 (Except Auto) (5/2001)

Use this form to request mid-term changes to any personal lines policy, except auto. For auto changes, see ACORD 71, Personal Auto Policy Change Request. This form should be used instead of individual turnaround endorsement requests. A copy of the request may be sent to the insured to confirm that the change is submitted to the company. The form provides for property, mobile home, inland marine, watercraft and umbrella changes. IDENTIFICATION This section provides essential producer, company and insured information. It should be fully completed for all types of changes. A copy of the policy's declaration page can be attached to provide additional identification information. All data fields in this section, except the insured's name and mailing address, should contain existing policy information, not changed data. The generic fields of the Identification section are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Sections of the Forms Instruction Guide. On the ACORD website (www.acord.org)., this information appears under the title PERSONAL LINES GENERIC SECTIONS. Most sections in this form begin with a change indicator. Enter either an A-Add, C-Change, D-Delete, or check the appropriate box. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a coverage, add a property location). Use "D" to delete an item (e.g., delete a property location). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). HOMEOWNER COVERAGES/LIMITS OF LIABILITY This section should be completed for any modification to the coverage amounts on a homeowner policy. If a new homeowner policy is to be written, the Homeowner Application (ACORD 80) should be used. When requesting a change, enter only the information being changed. All other items on the policy remain the same. If deleting an item, provide sufficient information to process the request. List the anticipated dollar limit amount for each applicable coverage. HO Form Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are: 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive. Deductibles One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) Dwelling Fire Coverages/Limits of Liability List the changed dollar limit amounts for each applicable coverage. Coverage Abbreviations Fire . . . . . . . . . . . . . . . . . . . . . . . . . . Fire and Lightning

EC . . . . . . . . . . . . . . . . . . . . . . . . . . . Extended Coverage VMM. . . . . . . . . . . . . . . . . . . . . . . . . Vandalism and Malicious Mischief One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) Mobile Home Coverages/Limits of Liability Enter the applicable coverage form and list the changed dollar limit amounts for each applicable coverage. One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) HOMEOWNER, DWELLING FIRE AND MOBILE HOME RATING/UNDERWRITING Provide the information below for each dwelling. Enter only the information being changed. Construction Type Check the primary type of building material used to construct the dwelling. Yr Built Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alternations in the Remarks section. Also complete the Renovation Update section. Sq Ft Dwelling's total square footage of living area. # Rooms Total number of rooms in a residence, including full and half rooms (bath). # Apts Complete only for tenant or condominium policies. Enter the number of apartments (residences) in the building. Market Value Estimated total dollar amount for which the dwelling could be sold under current market conditions. Replacement Cost Estimated total dollar amount required to rebuild the dwelling without depreciation. Structure Type Indicate the residence type. The full meaning of each abbreviation is: Dwelling . . . . . . . . . . . . . . . . . . . . . . Dwelling, intended to be a free standing, . up to 4 family building. APART . . . . . . . . . . . . . . . . . . . . . . . Apartment. CONDO . . . . . . . . . . . . . . . . . . . . . . Condominium. CO-OP . . . . . . . . . . . . . . . . . . . . . . . Co-operative. Usage Type Applicant's use for the dwelling within the guidelines listed. ("COC" refers to dwellings in the "course of construction.") # Families Number of separate family units in the dwelling. Not required for HO-4 or HO-6. # Hsehold Res Number of residents in the household. Purchase Date/Price Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format. # Units in Fire Div Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved fire walls. Terr Code Dwelling location based on individual state bureau or company homeowners manual pages.

Prem Group Premium group codes are found in individual state homeowner manuals. Some companies may require this data, others will generate it. Premium Group is a combination of Protection Class, Territory Code and Construction Type Code used to determine the applicable rate based upon the dwelling's location, construction and fire protection code. Protect Class Dwelling's four-character fire protection grade found in individual state homeowners manuals. Distance to Hydrant Distance in feet from the nearest hydrant to support the protection class used. Distance to Fire Station Distance in miles from the nearest fire station to support the protection class used. Protection Device Type For temperature, smoke and burglar alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies. Heat Type Type of heating device for the residence. If there is more than one type, indicate the primary and secondary types. Use the Remarks section if necessary. Some possible types are: · Electric - Permanent/Portable · Liquid Propane - Permanent/Portable · Natural Gas · Kerosene - Permanent/Portable · Coal -Professionally/Non-Professionally Installed · Oil · Wood · Solar · Other - Explain the heating system in Remarks Oil Storage Tank Location If the fuel type is oil, provide the location of the fuel oil storage tank. Examples: · Indoors completely above ground on a masonry floor · Indoors completely above ground not on a masonry floor · Outdoors and completely above ground · All other (including underground) Also show the distance from the dwelling, if the storage tank is outdoors. Renovation Type If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year. Dwelling Location Location of the dwelling within the guidelines listed. Occupied By Indicate if the dwelling is occupied by the owner or a tenant. Deadbolt If all entry (exterior) doors are fitted with deadbolt locks, check the box. Fire Extinguisher If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space. Visible to Neighbors If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box. Housekeeping Condition Enter the evaluation of the interior upkeep of the dwelling. Sprinkler If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system.

Swimming Pool If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board or approved fence. Storm Shutters Check the applicable boxes. Hurricane Resistant Glass Check the applicable box. Bldg Code Grade Enter the ISO Building Code Grade, if applicable. Also check the appropriate box to indicate whether or not the building was inspected. Tax Code Enter the city, county or state tax code, if required. # Weeks Rented Number of weeks the dwelling is rented by the insured to others. WIND CLASS Check the applicable box. Roof Type Enter the material used to construct the roof. Examples: · Composition (fiberglass, asphalt, etc.) · Metal · Poured · Slate · Tile · Wood Shake/Shingle · Other If used, explain in Remarks MOBILE HOME TIEDOWN/FOUNDATION Check the appropriate box to describe the type of tie down, if any, used to secure the mobile home from wind damage, and the type of foundation. ADDITIONAL INTEREST Provide the following information for the entity having an interest in the dwelling(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder, (e.g., bank in which the mortgage is held) or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number. Space is provided for two additional interests. PERSONAL INLAND MARINE/SCHEDULE OF PROPERTY List items that are to be added, changed or deleted on the personal inland marine policy. When working with a long list of items, you may attach a list of the items rather than complete this section of the application. When listing items, provide a full description, including serial numbers, if applicable. Appraisals or sales receipts must be included where required. WATERCRAFT COVERAGES/LIMITS OF LIABILITY Hull Amount of coverage for boat damage (this may include collision liability). Limits may be entered for two vessels. Outboard Motor Amount of coverage for damage to the outboard motor. Space for 2 motors is provided. · Coverage for inboard motors is included in the hull coverage. Portable Accessories Coverage amount for those items not permanently attached to the boat. Examples: · Oars · Anchors · Life preservers · Fire extinguishers Trailer Coverage amount for damage to the trailer.

Liability Coverage amount for bodily injury and property damage (may be called protection and indemnity). Medical Payments Coverage amount for medical expenses for bodily injury to occupants of the boat. Uninsured Boaters Liability Some states require this coverage for watercraft. Deductible Show the deductible if applicable. PERSONAL UMBRELLA COVERAGES/LIMITS OF LIABILITY Section may be used to make changes to either the basic policy or individual coverage limits. Policy Amount Limit of liability. Retention Amount of liability retained by the insured. Retention is usually expressed in whole dollars, but can be a percentage. Other Coverages, Automobile, Personal Liability, Watercraft, Recreational Vehicles Complete these boxes as needed. Producer's Signature / Insured's Signature Space is provided for signatures of the producer and/or the insured. Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are made that are considered significant to the company. Refer to your company rules. Many companies, or state laws require the insured's signature when certain types of coverage is changed or deleted. Refer to your company or state rules.

Workers Comp Insurance Plan 133 (4/96)

The Workers Compensation Insurance Plan Assigned Risk Section (ACORD 133) is designed to be used in conjunction with the ACORD Workers Compensation Application (ACORD 130). These two forms collect the data necessary for submitting assigned risk business. Please answer all questions thoroughly. Any omission may result in delay or denial of coverage. Where space restricts a complete answer, attach answer on a separate sheet of paper. These applications do not provide coverage. Refer to the National Council on Compensation Insurance Inc. (NCCI) WCIP State Instruction pages following this section for state specific instructions on completing the ACORD 133 and ACORD 130 for WCIP business. All questions regarding the preparation of this form should be referred to the NCCI Service Center shown on the state instruction pages. APPLICANT INFORMATION SECTION Applicant Name Enter the complete legal name of the employer. Provide all applicable D.B.A.'s (Doing business as). If more than one named insured, please submit appropriate ERM 14 form(s) "Confidential Request for Information." Contact NCCI for this form. Proposed Effective Date Enter the proposed policy effective date. Such requested effective date shall be the later of the following options. 1. 12:01 a.m. on the date following the receipt by the Plan Administrator of a complete and eligible application, 2. the date of expiration of existing coverage, or 3. a date the application requested. SUPPLEMENTAL INFORMATION Payroll Office Name and Address List the company name, physical address and telephone number where payroll records are maintained. A P.O. box address only is not acceptable. State Developing Highest Payroll

Enter the state which generates the highest payroll and follow all specific instructions for this state. 1. Prior Coverage question If there was no prior coverage, indicate why by checking the appropriate box for either new business, self insured (independent or group), or insufficient number of employees. 2. Premium Due or in dispute question Details of any outstanding obligations must be furnished in the available space, in the remarks section or on an attached separate piece of paper. 3. Year Applicant's Business Began List the month, day and year the current owners purchased or started the business. 4. Name/Ownership over 5 Years question A signed ERM-14 form "Confidential Request for Information," must accompany the application if a name or ownership change has occurred over the past five years, and has not already been reported. Contact NCCI for this form. 5. Related Entities question List all related entities, providing a detailed explanation of the type of relationship (e.g., management, ownership, etc.). 6. Do you lease workers from a labor contractor? Refer to the WCIP state instruction sheet for state requirements. 7. Do you lease workers to a client company? Refer to the WCIP state instruction sheet for state requirements. 8. Are you seeking to cover leased workers? Refer to the WCIP state instruction sheet for state requirements. 9. Do you provide temporary labor services to other employers? If yes, give a complete description of type of services provided (e.g., type of work being performed, duration, etc.) and a copy of the service contract, if available. 10. Do you have a franchise or licensing agreement? Provide details of agreement including franchiser's name and address. 11. Do trucking classifications apply? If yes, complete questions 12, 13, and 14. 12. Base Terminal question List the complete address for each base terminal which is used by the drivers to load, unload, and/or transfer freight on a regular basis. 13. Driver's State of Majority Driving Time question If the state of majority driving time can be established for each driver through verifiable logs or records, list the state for each driver in the appropriate section of question 14. 14. Drivers Listing The drivers listing should include the following for each driver: driver name base terminal (if applicable) state of majority driving time (if applicable) state of residence. INSURANCE COMPANIES WHO HAVE OFFERED/REFUSED INSURANCE 1. Have you received any offers of voluntary coverage? An offer of voluntary coverage will affect an applicant's eligibility for Plan coverage; therefore voluntary offers of coverage must be fully and completely described. 2. Refusing Insurance Companies information. Refer to the state instructions for requirements regarding the number of refusals needed before an applicant is eligible for the state's WCIP coverage. Refusal must come from non-affiliated insurers who are licensed and actively writing workers compensation insurance in the state of application. The employer and/or its representative must retain in file the refusing carrier's name, contact person, address, phone number and date of refusal. PREMIUM PAYMENT Several options are available for submitting deposit premium, including: 1. Verbal Check - Submit the complete nine (9) digit ABA number or bank routing number in the boxes provided under BANK/ABA #. Submit the complete account number and check number in the boxes provided. Indicate the premium amount (in whole dollars) which NCCI, Inc. is authorized to deduct from the account. The funds may be drawn on an agency or applicant's account which may be either a commercial or personal account. 2. Electronic Funds Transfer (EFT) - Submit the complete nine (9) digit ABA number or bank routing number, and the complete account number in the boxes provided. Indicate the premium payment amount (in whole dollars) which NCCI, Inc. is authorized to deduct from the account. The funds may be drawn on an agency or applicant's account. For this

option, a commercial account must be used. 3. Mail-In Check - Make check payable to NCCI, Inc. or other Plan Administrator, if applicable. The check may be in the form of an agency check, applicant's check, cashier's check, certified check, draft, money order, or finance company check. Coverage cannot be bound if the required deposit premium is not received. Please refer to the appropriate WCIP instructions for deposit premium requirements and premium calculation guidelines. APPLICANT'S STATEMENT This application must be signed by a sole proprietor, partner, corporate owner or officer. If a person other than any of these has signed the application (e.g., spouse, trustee, general manager), attach a copy of the power of attorney. With the signature, provide the signer's name, title and signature date. The Loss Sensitive Rating Plan acknowledgement applies only in those jurisdictions where the program has been approved for use. Reminder: Both the 130 and 133 applications must be signed by the insured and the producer. PRODUCER'S CERTIFICATION The following producer information must be completed: Agency FEIN (Federal Employer Identification Number), agency phone and fax number, resident or non-resident license number with expiration date, and the producer's name, date and signature.

Agent / Broker of Record Change 36 (1/98)

Use this form to provide authorization from your customer to the customer's current insurance company. The form notifies the insurer that you have been named as the exclusive representative with respect to policies currently in force.

Statement of No Loss (1/96)

Use this form when: A policy issued by your agency has been cancelled, or has lapsed, because premium for the policy was not paid in time; The former insured desires to pay the delinquent premium and reinstate insurance without a lapse in coverage; and Your contract with the insuring company, or the company's rules, permit policy reinstatement. (You may have to contact your company before proceeding.) By signing this form, the former insured certifies that there were no losses, or circumstances that might give rise to a claim under the policy, during the period coverage had lapsed. This form is also a receipt for the premium payment you collect at the time the form is signed. The form is NOT an insurance binder.

General Fraud Statement 63 (10/2001)

The following states have enacted anti-fraud statutes that prescribe specific fraud warning text for disclosure notices to applicants for insurance and/or claimants. In the case of claimants, the back of each ACORD loss notice contains the required fraud warning in compliance with state laws and regulations. NOTE: When a risk is located in moe than one state, the applicable law is the law in effect for the state in which the insurance policy is written, or the insurance claim is made.

California: All claim forms, and auto applications contain the required text. Colorado: ACORD 63 CO responds. Arkansas, Florida, Kentucky,New Mexico, New York: ACORD has secured agreement among these state regulators to recognize the "standard" fraud warning text included in all ACORD applications after 1/96. However, these states will no longer accept supplements such as ACORD 63FL, 63KY, and 63NY, which were withdrawn as soon as these states accepted our "standard" text. Companies with unique, program-specific applications should consider inserting ACORD's "standard" text, shown below, in their applications. "Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance 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 (NY: substantial) civil penalties." (Not applicable in CO, HI, NE, OH, OK, OR, VT, ) In DC, LA, ME, TN and VA, insurance benefits may also be denied. Hawaii: ACORD 63 HI responds. Idaho, Indiana, Nevada, New Hampshire: Claim forms only. District of Columbia, Louisiana, Maine, Tennessee and Virginia The "standard" ACORD fraud statement has been revised to respond to these states. Michigan, Minnesota: Regulators are enforcing law requiring specific fraud text in claim forms, but are not requiring that warnings be included in applications. Arizona, New Jersey, Pennsylvania, Tennessee: Claim forms and Applications. These states also accepted ACORD's "standard" text, and also recognize supplements to applications. Although not necessary with respect to ACORD applications, companies should consider using ACORD 63 with their unique, program-specific applications in these states, unless they have incorporated the "standard" ACORD text. Ohio, Utah: Claim forms and applications (Utah- workers compensation only). These states have specific, unique text requirements. ACORD 63OH, and 63UT meet these requirements, and should be used with ALL applications, ACORD or companyspecific. Oklahoma: Claim forms, insurance policies and applications. ACORD 63OK responds.

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