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