ACORD- HOMEOWNER APPLICATION

ACORD- HOMEOWNER APPLICATION OP ID SW DATE (MIVEMprenr) 06/02/2010 AGENCY nair inac c cNo mop 340-779-1799 inc.,00 340-779-1926 First Insurance: Port of Sale P.O. Box 306359 St. Thomas, VI 00803-6359 Tom Fit zatertons CODE: SUISCOOE: AGENCY CUSTOMER ID HIM APPLICANT INFORMATION PREVIOUS ADDRESS (Ilion than 3 yaws) APPLICANT'S NAME AND MAILING ADDRESS (Maud° county / ZIP•1) Tnhn L i TInannt-th -HNC CODE • • • 'AMITY COOT POLICY • NA On ." COIPLATIOnta. la IMMonirl tore • Lloyd.* 1 NOME PHONE CUM It OPECTF/E DATE EXPIRATION DATE BUSINESS MOM N 05/31/10 05/31/11 DAY EVE DAY EVE ISII:le°5 1,22-Marriets lieffisif•••mployed) GOVONOR COAP PI ICANT OCCUPATION ISIAlo new. 01 OOOOO SSW sinployfd) FINANCIAL ANALYST I KIW TONG HAY! YOU KNOWN THE APPLICANT COVERAGES/LIMITS OF UABIUTY RIO FORMI DWELLING ! IC03 1%700 000 OTHER I STRUCTURES I ! I 5 40000 PERSONAL I PROPERTY • i• 540,000. I LOSSOF USE s NIL PERSONAL UAUILITY I. ACII OCCURRENCE 3100,000. MEDICAL PAYMENTS EACH PERSON 4,000. ** - • * Au, PER.. — —.-_—.-- wirycjiHAR 'THEFT . lia5PC-AT ET I ,. . ...._._ ENDORSEMENTS • erflACOAFPP COST OWELL MG I I REPLACEMENT COST CONTENTS mum fle)01ISIEMENT(SI itsiDEDUCTIBLEt WINDSTORM HURRICANE, EARTHQUAKE WHICH IS 5% OF SUM INSU*ED EACH AND EVERY LOSS (SUBJECT TO MINIMUM OF $1,000). ALL OTHER PERILS $500 BACH SAM EVERY LOSS. YRS AT PREY ADDR APPLICANTS EMPLOYER NAME AND Aii SS VI GOVERMENT i Cifleetlekirieerktifelt AND IFTC INC LOCATION OP PROPERTY If OFF FROM ABM floc county 4 DPI nimbi MM., alaNOCC \JMOSS away fan/. STAT N -ores vain lft UE CrisMSPI. ImoTtan STAY N GATE AGENT LAST INSPECIFO PROPERTY: DATE OF BIRTH DATE OF BIRTH SOCIAL SECURITY • IAL SECURITY DED (Type & Amount) PREMIUM S EST TOTAL PREMES 12870 . 00 =POW 51. 54 OPAANIat 12921.54 PAYMENT PLAN I I ACORD 810 Attached (NOT APPLICABLE IN NC) ACCOUNT V: BILLWIC DIRECT All Xi AGENCY BI I RATING/UNDERWRITING IF ',ERECT BILL: [ HILL APPLICANT OTTER: BRE monrcaGet — 1-IF APPLICANT SW FULL PAY OTHER: MAIL POLICY TO. AGENT APPLICANT OTHER FRAME MI G HOME USAGE TYPE FARM xrIASOMM .VPALSKING 1970 12 s 950000 MASONRY MUMMA VENEER I SONG SOFT OMITS REPLACEMENT COST X DWELLING r TOWNHOUSE X 'PRIMARY APART ROOMS( • SECONDARY COMP- We 1 03G NUMBER OF I TIRE PREM 17ROTECT COTANCE TO CANDO 1. .LLGO-OP HEAT TYPE I,. 4 RENOVATION rrpens, xsts. x ORE RES 4595 I S 700000 T... I Mt C°°€ On FIRE DIV GROUP CLASS „„. • nee PROTECTIONOEVIDE TYPE j HONE WRING PLUMBING X 01 1 STATOR SYSTEM] SIAOICI TEMP funpoly. CEFITRAL INERC IIATE TIRE DISTRICT/COOE NUMBER °snot I SECONDARY NEATNG HOUSEKEEPING CONDITION I RomiNG DATE RIMING SYSTEM' I Num or ARPS DIRCUIT BREAKERS FUSES , AST tEliTical) (ELFC STET) [ ALuimmisi WONG CONDITION foLloualloweresr vomerecevemnififighnow ANT KNOWN LEAKS S X NoNE CLOSED 02 EXTEROR PAINT 1 LOCH Csolosknufm I X YES 1.2 X YES LI M3 ' 1 yEs [ I No Good DEAODDLT . . OIL STORAGE TAM( LOCATION STARRING °NEWF* LOCATION oc6upoinci - WY LOAN'S UNOCC X FIRE EXT INDOORS OUTDOORS VOW° WITHIN X I - ▪ °GNI It mum ti 'VETERE T — ERVING ABOVE Al ORE KIST WITHIN PROT TENANT VACANT _& NEIGHBORS POS. *suss OROUND ANN OPANIPIS citiiissei rims 61-60C°°C INSPECTED? TAX CODE RATIN GRACE o_IC J • . • • If REPLACEMENT COST PERLIS: ACOROT BASEMENT " "lieTriMN SO I ACORD 80 (2003109) SOFT O we Kivu i—treol LRESISTNE DAILY? .,1 rn ATTACHED I RATING CREDITS .f_ - eateittiiiiir—til NON-SMOKER x I I SOFT 1-... II PROTECTION I - • ABOVE GROUN WOW GROUN RENTECIN° GUISE SE CU OFF PREMISES 'HIFI FXCI PLEASE COMPLETE REVERSE SIDE - SLIDE GROUND ROOF MATERIAL ROOF RESISTIVE OTHER 1.224BRANE 000C, SPRINKLER , FIREPLACES (EMit Flumbet) minim CHIMNEYS r PRE-FAIT I-. WOOD STOVE Fs HEARTHS I INSERT ACORD CORPORATION 1981 PAM. LIES • HEINLE No OPEN STORM SHUTTERS HU > d YES n M Its PURCHAS DAT E E/PRICE e GLASSFNO EFTA01221608 GENERAL INFORMATION 2 apuvN ALL -yor RESPONSES IN REMARKS YES ANY FAHLMO oft lEavdog ayc"'J • ANY itiotrbei end two d 6.4I and pal tan ansayasa 3 ANY F 1001)1Na. BRUSH, FOREST FIRE HAZARD. LANES IDE ETC, ANY (RIRIE RE SONIC( OWNED OCCUIRO ON MENINX? • ANY 011 Wit INSURANCE WITH TIM COMPANY/TUE pc4cy nullibanN . . 4 INS INNIFLANCE KEN TRANSFERRED WITHIN AGENCY' • ANY COVERAGE. DECUTRO. CANCA II CD Olt NONRENEWEO ouppo Tot LAS! 3 YEARS, (101400ceMon MO) a las APPLICANT HADA FORECLOSURE. nrivssessioN. IIANKRUPTCY. JUDGEMENT MI LEN DURING TIC PAST FIVE Yi.ARS2 9 ARE THERE ANY AMELMS OR EXOTIC PETS KEPT ON PREMISES? (14010 brad and OM Walt !It IS PHOPERTY L °CARO WIDEN MO MILES OE TRIAL WATER? Is B PROPERTY SITUATED ON MORE TIM ENE ACRES? (II yas. desalt* and vie) I). DOES APPLICANT OWN MN RECREATIONAL VEHICLES 'SNOW MOBILES. DIME BIGOTS. MINI BIKES. ATVS. EICN TUN sm. ON. Tab. meg 13 IS OLIN DING RE IROFITTEO FOR EARN/CLIME? .100/Kattel 1 MD EXPLAIN ALL •YES• RESPONSES IN REMARKS (EKcepl queellian 15. 16 and 1T) TES IK — -l47 191AIMOVItE MS i FIVEVEAAS I Ii N rtats ortaiocit IsC ir X HAS NIT APPUCANI BEEN CONVICTED Or ANY DECREE OF THE CRIME Of ARSON? Dr, RI. Mae sy cAscase SW 'mane Wan wan commas ts a rosaameadot passable a s mance 0 up loom X year cd agnomen, 1 1 X IS. IS MERE A WOMGER ON THE PREMISES? RE ... AYERS AND -. — A .. . CCNDOS MAY 16. WHERE A SECURITY ATTENDANT, ... . . ._. _ .. . .. . . ... . .. ... _ , „ IT. IS THE 01111011.G ENTRANCE LOCKED? - ...• • • X III ANY UNCORRECTED FRE OR BUILDING COO VIOLATIONS? : X i ill is euitoins uwootooi.c nbac‘/A i ion on tiEdliGlillete010 " . - .i: (Ma esionated comiaann dale ma 005.1 WON) X L... ...._....._.. _............_.....___. ..... _...__.._.._._._ .. .. _ 20 IS I OUSE FOIL SALE? X 11 IS PITOPERTYIfiN3COODIAOONMETLCIN.Ort — -- - - — - --- -- . -1—" . X DZSCAT X X 22. IS THERE A TRIMAPOTLINE ON THE PREMISES? 23. WAS ME STRUCTURE ORIGINALLY WILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? 24. ANY LEAD PARR HAZARD? X X X ANY LOSSES. WHETNER OR HOT pAiDBY INSURANCE, DURING THE LASTS_ YEARS. AT THIS OR AT ANY OTHER LOCATION? 26. IF A FUEL OIL TAW SON PREMISES. HAS OTHER MRIRANEE BEEN OBTAINED rout THE TANK? Olve Fail Party and INK and mad Party and Im11) 26. IF BLIRDING IS UNDER CONSTRUCTON. IS TIE APPLICANT THE GENERAL CONTRACTOR? X X X X Xx LOSS HISTORY I YES J ] NO IF YES. INDICATE BELOW APPLICANTS MIMES: CAT I/ DATE I TYPE DESCREITION OF LOSS AMOUNT PRIOR COVERAGE PRIOR CARRIER PRIOR POLICY 'ENRON EXPIRATION DATE ADDITIONAL INTEREST Wra Lwow : /LAME AND ADDRESS immteri l Firot Bank ;P.O. Box 309600 St. Thomas VI 00803 • LOAN NUMBER REMARKS (Attach Additional Sheets If Moro Spans Is Required) ATTACHMENTS STATE SUPPLEMENTS:DI apicat* I PROTECTION DEVICE CERTITCATT INLAND MARINE APPLICATION PERS EXCESSAJIAMELLAAPP REPLACEMENT COST ESTIMATE RECREATIDNAL VEMCLE API' .._ _ . PHOTOGRAPH WATERCRAFT APPLICATION SOLID FUEL SUPPLEMII NT LEAD FREE PAINT Cr IMF/EATON EARTHQUAKE APPLICATION HOME EAST D BuS INE SS Sufi' TOR COMPANY USE ONLY 0 IN DER/SIGNATURE INSURANCE EFFECTIVE OATS _ . .. 'Sc i . COVERAGE IS NO FENDER EXPIRATION _ I BOUND DATE N THE -BINDER' BOX TO THE LEFT IS COMPLETED, THE FOUL:MN° CONDITIONSAPPLY: TINS COMPANY WOOS TIN MID(S)Ct iNSURINCE STIPULATED ON THIS APPLICATION. THIS INAIRANCE IS SUBJECT TO THE TERMS. CONDOIONS AND LIMITATIONS OF THE POLICY(CS) IN CURRENT USE BY THE COMPANY. THIS BINDER MAY BE CANCELLED BY TIDE INSURED BY SURRENDER 01 THIS DIMIER OR NY WRITTEN NOTICE 70 ME COMPANY STATING MIEN CANCELLATIONWILL DE EFFECTIVE THIS BINDER MAY OE CANCELLED BY ME COMPANY BY NOTICE TO 1.IC INSURE 0 IN ACCORDANCE WITH THE POLICY CONDITIONS II IR ENDER IS CANCELLED WHEN REPIACELI UT A POLICY IS I HIS HINDER IS NOT REPLACED BY A POLICY. THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR ME ROGATION ACC.ORDING TO THE RULES NO RATES IN THE OY lliE COMPANY THE OUOTED PRELIM.. IS SUBJECT TO KNIT ION AND ADJUST...M.WHEN NECESSARY. BY THE COMPANY. 12'.01 AM.. —. . NOON in MON. 'KORNAI ION NOVI YOU INCI MANG IN ORLIATION FROM A CREDIT REPORT. MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN OMNI C HONWIIn 116 MEI ICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS/KID RENEWALS CREDIT SCORING INORMATION MAY EC USED TO 'Ir II WWI HITHER EMOTION. ITY FOR INSURANCE OR THE PREMIUM YOU WEL OE CHARGE 0 WE MAY USE A TIERD PARTY IN CONNECTION WITH THE JI VII (WIC NI 01 VI UR SCORE SUCH INFORMATION AS WELL AS OTTER PERSONAL &NU MIA (CEO INOTU4M-01 COT I I Cl L D OY US OR OUR AGENTS MAY Wait !AN cHNIAISI ANC, S BE CCCLOSED TO 111.110 PAR IMPS WITHOUT YOUR Au MORVATION YOU HAVE Till INGOT ID REVIEW YOUR PERSONAL INCEREATION IN OUR FILLS AND CAN REQUEST CORRECTION O. ANY NACCUNACES. A MOM OE TAILED OESCRIPTPM OF YOUR RIGHTS AND OUR PRACTICES RI CARDING SUCH MOH/M.710N IS AVARAOLE VON REOUEST CONTACT YOUR AGENT OR BROKER I OR INSTRUCI IONS ON HOW TO SUBMIT A M OM SI TO US LI COPY Or DIE NOTICE Or INFOWAA NON PRACTICES WRIVRNI HAS Ill ER GIVEN TOME APPLICANT INN salsa, in EaleiesI ANY MORON 1,40 KNOWN GI YAM) VOIR INTENT 10 MERANO NW INSURANCE COL.PANY OR ANOTHER PERSON FILES AN APPLICATION ron INSURANCE 0/1 S i A NEC( T Of CLAM CONTAINER ANY MATE RIAI LY FµSE INT ORMATIC.I. OR CONCEALS FOR TIE PURPOSE OF MSLEADING INFOIDAMION COMM MING ANY FACT MATERIAL THERETO. COMAIIS A FRAUDULENT INSURANCE. ACT. WHiCII IS A COME ANO SUDJECTS THE PERSON TO MINION. MO ANY MSS TANI WU CNN PENN TES INN appinala m CO. N. NE. 011. OK. OR. a VT: in DC. LA ME. TN end VA. idaworce bonefts may Ma De Mad) AIMS ICARUS STATEMENT I HAVE. OEM ME .1ECNE APPLICATION AND MN MEACHAM HIS I DI CLARE TINT HE INFORMATIONPROVIDED IN THEM IS TRUE. COMM EN AND CORRECT TO TIC BEM OE MY WY/LEDGE NAID BELIEF. 1145 INT ORMA HON IS APING OFFERED TO 111E COMPANY AS AN INDUCEMENT TO ISSUE 7 N^I Olt FOR TM A DATE 4 1 PRODUtECS SIGNATURE I NATIONAL PRODUCER NUMBER I Tom Fitzsimmons .5 - .2/ ACOR EFTA01221609 Insurance ACIENCV,1 MC. Firs Insurance. Port of Sale P.O Box 306359 St. Thomas VI 00803-6359 340-779-1799 ENCLOSURE RENEWAL AGREEMENT Named Insured: John & Cecile DeJongh Insurance Company: TYSER & CO LTD. Expiring Policy Number: Expiring Policy Date: 05/31/10 Renewal Effective Date: 05/31/10 Renewal Premium: $12,921.54 IN CONSIDERATION OF THE PREMIUM CHARGED, IT IS HEREBY UNDERSTOOD AND AGREED THAT THE INSURANCE COVERAGE PROVIDED BY THE RENEWAL OF THE ABOVE POLICY IS SUBJECT TO THE SAME TERMS AND CONDITIONS AS THE EXPIRING POLICY. THESE TERMS AND CONDITIONS INCLUDE THE DECLARATIONS MADE AT THE TIME THE PREVIOUS APPLICATION WAS TAKEN AND THAT INFORMATION IS HEREIN INCORPORATED AS THE BASIS FOR THE RENEWAL OF THIS POLICY OF INSURANCE. AC ED (NA ED I RED) DAT EFTA01221610