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Homeowners Application Broker Information   Today's Date: Broker Name: Broker Contact:   Broker Contact Telephone: Broker Contact Fax: Broker Contact Email: Insured Information   Proposed Effective Date Named Insured   Insured Location Address Insured Location City   Insured Location State Select a State Not Applicable New York New Jersey Connecticut Pennsylvania Insured Location Zip   Insured Social Security Number #1   Insured Date of Birth #1   Insured Social Security Number #2   Insured Date of Birth #2   Policy Form Select a Policy Form HO3 HO4 HO5 HO6 Dwelling Amount   Dwelling: Detached                Attached Liability Limit   Select a Limit $100,000 $300,000 $500,000 $1,000,000 Medical Payments   Select a Limit $1,000 $2,000 $3,000 $4,000 $5,000 Deductible   All Perils  Select a Deductible $100 $250 $500 $1,000 $2,500 Wind/Hail Select a Deductible 2% 5% Hurricane Select a Deductible 2% 5% Replacement Cost Dwelling  Yes             No Replacement Cost Contents  Yes             No Off Premises Theft Exclusion  Yes             No Construction: Masonry        Frame       Fire Resistive   Year Built #families Select # Of Families 1 Family 2 Family 3 Family 4 Family purchase date protection class Select Protection Class 1 2 3 4 5 6 7 8 9 Heat Type:  Gas            Electric          Oil Oil Tank Location Above Ground          Below Ground Protection Device Type Local    Central Station    None Pool Yes         No Dog Breed Claims History Additional Endorsements Final Quote and Binding Subject to Completed Signed Application Yes: * By checking "YES" you agree to and understand the above.

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