ADDITIONAL INTEREST (Attach ACORD 45, Additional Interest Schedule, if more space is required) ACORD 80 (2009/10) Page 4 of 5

GENERAL INFORMATION - RENTERS AND CONDOS ONLY LOC #: ACORD 80 (2016/11) Page 4 of 6

ACORD 610 Attached (NOT APPLICABLE IN NC) ACCOUNT #: MAIL POLICY TO: BILLING IF DIRECT BILL:

REMARKS (Attach ACORD 101, Additional Remarks Schedule, for any remarks) BINDER / SIGNATURE ACORD 80 (2010/05) Page 5 of 5

The ACORD name and logo are registered marks of ACORD PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required) ... ACORD 80 (2010/05) Page 2 of 5

ACORD Forms are now available in a variety of formats, including printable PDF, electronic fillable, and eForms. Using ACORD's standardized Forms allows for increased efficiency, accuracy, and speed of information processing.

ADDITIONAL INTEREST (Attach ACORD 45, Additional Interest Schedule, if more space is required)

ACORD 610 Attached (NOT APPLICABLE IN NC) ACCOUNT #: MAIL POLICY TO: BILLING IF DIRECT BILL:

ACORD 80, Homeowner Application, is used in the underwriting process for the homeowners line of business. Enter date: The date on which the form is completed. (MM/DD/YYYY) Enter text: The full name of the producer / agency. Enter text: The mailing address line one of the producer / …

ENDORSEMENTS - See Page 4 ... ACORD 80 (2006/10) RPORATION 1981-2006. All rights reserved. The ACORD name and logo are reg