For Help Call (919)-290-6000     NAME, ADDRESS AND CONTACT INFORMATION Fields marked (*) are mandatory.   First Name* Last Name* Home Phone* Work Phone Ext: E-mail* Reffered By Please select Local Newspaper Yellow Pages Billboard TV Commercial Referral Search Engine Friend Partner Site Ad Other SSN # Rate your credit Please select Excellent Good Poor

For Help Call (919)-290-6000     PRIOR INSURANCE Fields marked (*) are mandatory.   Have prior insurance: Please select No Present Insurance AIU Insurance Allmerica Fin'l Benefit Ins Co Allstate Insurance Allstate Indemnity American and Foreign Ins Co American Bankers Ins Co of FL American Deposit Insurance American Home Assurance Co American International South American Mfrs Mutual Ins Co American Motorist Ins Co American National P & C Co American Premier Insurance American Protection Ins Co AMEX Assurance Company Amica Mutual Insurance Atlanta Casualty Company Atlantic Mutual Insurance Co Auto-Owners Insurance Co CGU Insurance Charter Oak Fire Insurance Cincinnati Insurance Co Colonial Penn Franklin Insurance Dairyland Insurance Deerbrook Ins Electric Insurance Company Esurance Federal Insurance Company Fidelity & Casualty Co of NY Fidelity & Guaranty Ins Undrs First Floridian Auto and Home Insurance Company First Liberty Insurance Corporation First National Ins Co of Amer GEICO General Insurance GEICO Casualty Company GEICO Indemnity Company General Accident Insurance Government Employees Insurance Hartford Accident & Indem Co Hartford Casualty Ins Co Hartford Fire Insurance Co Hartford Ins Co of Midwest Hartford Ins Co of Southeast Infinity Insurance Integon General Ins Corp Integon Indemnity Corp Integon National Insurance Co Integon Preferred Insurance Co Kemper Insurance Liberty Insurance Company Liberty Mutual Fire Insurance Lumberman's Mutual Casualty Co Massachusetts Bay Ins Co Merastar Insurance Company Metropolitan Casualty Ins Co Metropolitan Prop & Cas Ins Co Metropolitan General Ins Co MIC General Insurance Corp National General Assur Co National General Ins Co National Interstate Ins Co Nationwide Mutual Fire Insurance Nationwide General Insurance Nationwide Assurance New Hampshire Indemnity Omni Indemnity Omni Insurance Owners Insurance Company Pacific Indemnity Company Progressive Casualty Ins Co Prudential Prop & Cas Ins Co Regal Insurance Response Insurance Company Royal Ins Co of America SAFECO Ins Co of America Sentry Insurance Mutual Co St Paul Guardian Ins Co State Auto Prop & Cas Ins Co State Farm Fire & Cas State Farm Mutual Auto Superior Insurance Company Teachers Insurance Company TIG Indemnity Company Travelers Indem Co of Amer Twin City Fire Insurance Co United Services Auto United States Fid & Guar Co USAA Casualty Insurance USAA General Indemnity Victoria Fire & Casualty Co Windsor Insurance Worldwide Insurance Company Present company not listed Please select No Present Insurance AIU Insurance Allmerica Fin'l Benefit Ins Co Allstate Insurance Allstate Indemnity American and Foreign Ins Co American Bankers Ins Co of FL American Deposit Insurance American Home Assurance Co American International South American Mfrs Mutual Ins Co American Motorist Ins Co American National P & C Co American Premier Insurance American Protection Ins Co AMEX Assurance Company Amica Mutual Insurance Atlanta Casualty Company Atlantic Mutual Insurance Co Auto-Owners Insurance Co CGU Insurance Charter Oak Fire Insurance Cincinnati Insurance Co Colonial Penn Franklin Insurance Dairyland Insurance Deerbrook Ins Electric Insurance Company Esurance Federal Insurance Company Fidelity & Casualty Co of NY Fidelity & Guaranty Ins Undrs First Floridian Auto and Home Insurance Company First Liberty Insurance Corporation First National Ins Co of Amer GEICO General Insurance GEICO Casualty Company GEICO Indemnity Company General Accident Insurance Government Employees Insurance Hartford Accident & Indem Co Hartford Casualty Ins Co Hartford Fire Insurance Co Hartford Ins Co of Midwest Hartford Ins Co of Southeast Infinity Insurance Integon General Ins Corp Integon Indemnity Corp Integon National Insurance Co Integon Preferred Insurance Co Kemper Insurance Liberty Insurance Company Liberty Mutual Fire Insurance Lumberman's Mutual Casualty Co Massachusetts Bay Ins Co Merastar Insurance Company Metropolitan Casualty Ins Co Metropolitan Prop & Cas Ins Co Metropolitan General Ins Co MIC General Insurance Corp National General Assur Co National General Ins Co National Interstate Ins Co Nationwide Mutual Fire Insurance Nationwide General Insurance Nationwide Assurance New Hampshire Indemnity Omni Indemnity Omni Insurance Owners Insurance Company Pacific Indemnity Company Progressive Casualty Ins Co Prudential Prop & Cas Ins Co Regal Insurance Response Insurance Company Royal Ins Co of America SAFECO Ins Co of America Sentry Insurance Mutual Co St Paul Guardian Ins Co State Auto Prop & Cas Ins Co State Farm Fire & Cas State Farm Mutual Auto Superior Insurance Company Teachers Insurance Company TIG Indemnity Company Travelers Indem Co of Amer Twin City Fire Insurance Co United Services Auto United States Fid & Guar Co USAA Casualty Insurance USAA General Indemnity Victoria Fire & Casualty Co Windsor Insurance Worldwide Insurance Company Present company not listed If Other Insurer is selected Enter Insurer Name Have Insurance with them for* Please select Less than a year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 and more Estimated Yearly Premium (in US$) Prior Policy Ends On* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

For Help Call (919)-290-6000     PROPERTY GENERAL Fields marked (*) are mandatory.   Address 1* City* State* Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Property Surroundings* Please select Inside City Limits Outside City Limits, fringe Isolated Distance to Fire Station* Please select Less than 5 miles 5-9 miles Over 9 miles Distance to Hydrant(ft)* Under 1000 Over 1000 Year Built* Property Use* Please select Primary (non-seasonal) Secondary (non-seasonal) Seasonal Farm Vacant Occationally Occupied Square Footage* Number of Families* 1 2 3 4 Number of Stories* 1 2 3 4 Dog Type* No Dog Chow Chow Doberman German Shepherd Pit Bull Rottweiler Wolf Hybrid Other

For Help Call (919)-290-6000   PROPERTY VALUES Fields marked (*) are mandatory.   Purchase Date* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Purchase Price* Est. Current Market Value* Est. Replacement Value*

For Help Call (919)-290-6000      CONSTRUCTION DETAILS Fields marked (*) are mandatory.   Construction Type* Please select Brick Brick Veneer Frame Log Non-Combustible Pre-Fabricated Other Roofing Material* Please select Asphalt Shingle Gravel Tile Wood Shingles Other Age of Roof Electrical Type* Please select Copper Aluminium Other Heat Type* Please select Coal Non-Professionally Installed Coal Professionally Installed Electric Natural Gas Oil Liquid Propane Gas Number of Fireplaces* Please select 0 1 2 3 4 5 6 7 8 9 10+ Number of Bathrooms* Please select 0 1 2 3 4 5 6 7 8 9 10+

For Help Call (919)-290-6000   PROTECTION DEVICES Fields marked (*) are mandatory.   Burglar Alarm* Please select None Local Central Direct Both Local and Central Fire Alarm* Please select None Local Central Direct Both Local and Central Smoke Detectors* Please select Each Room Not Each Room/Not sure Fire Extinguishers on Each Floor* Yes No Not Sure Fire Sprinkler System* Please select Not available Partial Full

For Help Call (919)-290-6000   BUILDING DETAILS Fields marked (*) are mandatory.   Number of Basements* 0 1 2 3 4+ Basement Sq. Footage(est.) Basement Finished Percentage(est.) Not Applicable 100% 90% 75% 50% 25% 10% 0% Garage Type* Please select Attached Detached No Garage Garage Sq. Footage (est.)

For Help Call (919)-290-6000   OTHER STRUCTURES Fields marked (*) are mandatory.   Swiming Pool Type* No Pool Pool Above Ground Pool in Ground Swiming Pool Fence Construction Type Not Applicable Plastic/Vinyl Siding Metal/Plastic Siding Steel Has Diving Board Yes No

For Help Call (919)-290-6000   ADDITIONAL INFORMATION Fields marked (*) are mandatory.    The questions bellow will help the Insurers to determine the best discounts to be awarded Have you had any reported losses during the past 3 years?* Yes No Any business conducted on premises? (including day/child care)* Yes No Any residence employees?* Yes No Has application had a foreclosure, repossession or bankruptcy during the past five years?* Yes No Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?* Yes No Is building retrofitted for earthquake?* Yes No Not Sure

For Help Call (919)-290-6000   BASIC COVERAGES Fields marked (*) are Mandatory Coverages.   COVERAGE NAME LIMITS                            %BASE Dwelling*  Other Structures*   Personal Property*   Loss of Use*   Personal Liability* Please select $100,000 $200,000 $300,000 Medical payments* Please select $1,000 $2,000 $3,000 DEDUCTIBLES All Perils Deductible* Please select $250 $500 $1000 $2000 CREDITS Non-Smoking Household Yes No