GABRIELE BRIDGES 8/9/2013-8/9/ DP3 STANDARD. Date of Birth ***-**-**** Social Security Number SINGLE. Cell Phone

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1 APPLICATION DETAIL Insured Effective-Expiration Date Policy Number Form Program GABRIELE BRIDGES DP3 STANDARD AGENCY INFORMATION Agency Number Agency Name Address City, State Zip Phone Number DIRECT SOURCE INS. SERVICE, INC WILLIAMS BLVD SUITE 32 KENNER, LA (504) APPLICANTCO-APPLICANT INFORMATION Applicant Name GABRIELE BRIDGES Date of Birth Social Security Number Marital Status Home Phone Cell Phone Work Phone Address Preferred Contact Number Passport Number Years Present Job Description of Nature of business if self employed Where is business conducted if self employed? # of clients on property per day Prior Length of time previously employed School Name If student, class standing Co-Applicant Name Date of Birth ***-**-**** Social Security Number SINGLE Marital Status (504) Home Phone (504) Cell Phone Work Phone Address Preferred Contact CELL Number Passport Number EMPLOYED 2 Years Present Job TEACHER- JOHN CURTIS Description of 0 Nature of business if self employed Where is business conducted if self employed? # of clients on property per day Prior Length of time previously employed School Name If student, class standing PROPERTY ADDRESS MAILING ADDRESS Address Option Line City, State Zip Parish 2012 ILLIIS AVE Address 2012 ILLIIS AVE Option Line KENNER, LA JEFFERSON City, State Zip KENNER, LA LPIC DPAPP

2 BASIC COVERAGE LIMITS AND PREMIUMS Coverage Coverage A - Dwelling Coverage B - Other Structures Coverage C - Personal Property Coverage D - Fair Rental Value Coverage E - Additional Living Expense Coverage L - Personal Liability Coverage M - Medical Payments Ordinance or Law Limit $115,000 $11,500 $20,000 $11,500 $100,000 $1,000 $11,500 Premium $1,785 $521 $51 DEDUCTIBLES All Other Peril (AOP)Calendar Year Named Storm Deductible $2,500 $2,300 OPTIONAL COVERAGES, DISCOUNTS, FEES AND SURCHARGES Coverages Coverage B - Specific Structure Specific Structures Description: Apply Limit Permitted Incidental Occupancies - Residence Incidental Occupancy Description: Vandalism & Malicious Mischief Coverage Extended Coverage NE Discounts Applied Discounts Applied Protective Device - Burglar Wind Mitigation - Complete Opening Protection Protective Device - Fire Wind Mitigation - Hip Roof Protective Device - Sprinkler Wind Mitigation - Building Code Fee Description Fee Amount Fixed Expense $65 Inspection $25 Citizens FAIR Plan Assessment $61 PREMIUM Subtotal (Basic Coverage, Optional Coverages, Discounts) Total Fees Total Premium $1,623 $151 $1,774 PRIOR CARRIER Company Prior Insurance Expiration Date X None FLOOD INSURANCE Company AMERICAN BANKERS Policy Number Policy Number AF LOSS HISTORY X None Date of Loss Loss Description Type of Loss Amount of Loss DWELLING INFORMATION Construction Type FRAME Square Footage 1,156 Residence Type SINGLE Foundation CRAWL SPACE Year of Construction 1950 Occupied By OWNER Number of Stories 1-Story Occupancy PRIMARY LPIC DPAPP

3 Market Value $159,900 Replacement Cost $120, Territory 260 Protection Class 2 Flood Zone X Years Owned 0 Roof Type SHINGLE-COMPOSITION 1,000 ft or Less to Hydrant 1000 Feet or Less Primary Heat System CENTRAL HEATAIR Secondary Heat System NE Describe Primary Heat Source Number of Families 1 Fire Station STATION 35 Number of Rooms 6 Dead Bolt DWELLING REVATION Describe Secondary Heat Source Units in Fire Division <7 Miles to Fire Station Smoke Detector Fire Extinguisher Type PartialComplete Year Renovated Comments Roof COMPLETE 2012 Wiring PARTIAL 2012 Plumbing PARTIAL 2012 Heating COMPLETE 2012 Exterior Paint COMPLETE 2012 SWIMMING POOL Is a Swimming Pool on the Premises? Type Approved Fence? Size If no Approved Fence, Explain. Diving Board Slide PREVIOUS ADDRESS 1 - ONE 7 miles or less Address: Years Owned: 0 POLICY INTEREST Type MORTGAGEE Name and Address INTERLINC MORTGAGE SERVICES LLC ISAOA Interest Bill To ATIMA W SAM HOUSTON PKWY N Loan ID SUITE 200 HOUSTON, TX Phone # Fax # Type Name and Address Interest MORTGAGEE JEFFERSON PARISH DEPARTMENT OF Bill To COMMUNITY DEVELOPMENT 1221 ELMWOOD PARK BLVD. Loan ID SUITE 605 JEFFERSON, LA Phone # Fax # UNDERWRITING INFORMATION 1 Is there any business conducted on the premises, including home day care? If yes, is it a childdaycare business? 2 Do applicants have any resident employees? If yes, explain: 3 Any Coverage Declined, Cancelled, andor Non-Renewed in the last 3 Years? If yes, explain: 4 Has applicant had a foreclosure, repossession or bankruptcy during the last 5 years? If yes, explain: 5 Are there any farm animals or exotic animals on premises? If yes, explain: 6 Do applicants or tenant have any animals? If yes, describe the type of animal and, if a dog, list the breed. If the dog is a mixed breed, what breeds? 7 Is dwelling located on more than 5 acres? LPIC DPAPP

4 8 Does the applicant own any recreational vehicles (jet skis, snowmobiles, dune buggies, mini-bikes, ATV ATV Insurer ATV Policy ATV Exp Dat 9 Is residence for sale? 10 In the last 10 Years, has Applicant been convicted of any degree for Arson? 11 Is Property within 300 feet of Commercial or Non-Residential Property? If yes, explain: 12 Was the structure originally built for other than a private residence and then converted? If yes, explain: 13 Is there a trampoline on the premises? 14 Is dwelling visible from the road and to neighbors? 15 Is there an underground fuel tank on the premises? If yes, distance from house (ft): 16 Has there been a lapse in coverage of more than 30 days 17 Is this a new purchase? If yes, what is the closing date? Any screened enclosures other than for a pool? 19 Any flooding, brush, forest fire hazard, landslide, etc.? If yes, explain: 20 Any uncorrected fire code violations? 21 Any other residence owned, occupied, or rented? If yes, Explain: 22 Has insurance been transferred within the agency? 23 Is residence undergoing renovations? If yes, explain: 24 Is residence occupied by applicant andor co-applicant? FLOOD EXCLUSION I understand this policy does not cover losses resulting from any type of flood, regardless of how caused and that it is my responsibility to purchase a separate flood policy. Lighthouse Property Insurance Corporation urges all policyholders to purchase this valuable coverage. Applicant Signature Date APPLICANT SIGNATURE I apply to the Company for a policy of insurance as set forth in this application on the basis of the statements contained herein, I agree that such policy shall be null and void if such information is false or misleading in any way that would affect the premium charged or eligibility of the risk based on company underwriting guidelines. I understand the company routinely will inspect the insured location. If a discrepancy from information provided in this application is found during inspection, I give the Company the authority to change the policy. Further, I understand this may cause a change in premium. I understand the application is not a binder for insurance unless indicated as such on this form by the brokering agent. I understand that payment of premium is defined as being only when the premium payment check clears, and no temporary or other coverage exists unless the check clears when initially submitted by the company or its agent. I hereby certify that I have read and answered all questions on this application. I also certify that all information contained in this application is accurate and complete. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicant Signature Date Time Co-Applicant Signature Date Time LPIC DPAPP

5 AGENT'S SIGNATURE A copy of the application has been furnished to the applicant or insured and coverage is: Bound effective (Date) (Time) AM PM Not Bound Agent Signature Agent Number BILLING INFORMATION Initial Payment By Insured Bill To At Renewal: MORTGAGEE Payment Options Available: 1 -Pay 2 -Pay 4 -Pay Installment Fee: X Make Checks Payable to LIGHTHOUSE PROPERTY INSURANCE and write policy number on your check. LPIC DPAPP

6 CHECKLIST FOR AGENT Supporting documentation must be maintained in the Agent s file unless noted otherwise. Failure to provide requested documentation for future audits will result in the removal of the credit or application of a surcharge and an invoice to the insured. Application - Completed application, signed by the insured and agent Protective Devices Discount - certificate for reporting or central reporting burglar andor fire alarms and sprinkler system Renovation Discount - Contracts from licensed contractors are required as documentation of renovations meeting discount requirements and should be submitted to company. Prior Insurance - copy of prior declarations page(s) for prior 12 months. Wind Mitigation Discounts - a Windstorm Mitigation Survey completed and signed by a licensed contractor or other acceptable documentation. Photos of home showing all sides of roof for hip roof credit. Submit to company within 10 days of policy inception date. 4 point inspection or other documentation showing roof, electrical, plumbing andor roof updates. Submit to company. Agent Signature Agent Number CONSUMER REPORT DISCLOSURE Lighthouse Property insurance Corporation and its subsidiaries may use consumer reporting information in underwriting your insurance and setting premiums. This confidential information is used to help us determine eligibility for coverage as well as calculating your most accurate premium quote. As your insurer, we are committed to ensuring that you obtain quality coverage at the lowest possible rate. We may collect your consumer report information, including an inspection of the property, from third party companies. These companies do not make decisions in determining eligibility or premium development and are unable to provide you with details regarding eligibility and quoted premium. You may contact the following consumer report agency within 60 days of this notice to obtain a free copy of your consumer report and have the ability to dispute the accuracy of completeness of this report. Loss History Inquiries Insurance Services Offices A-Plus Consumer Inquiry Center 545 Washington Blvd, LOC 22-6 Jersey City, NJ (800) Additional Privacy Compliance Information Privacy Compliance Lighthouse Property Insurance Corporation 5545 S. Orange Ave. Orlando, FL (888) REMARKS LPIC DPAPP

JULISSA E POLANCO 5/29/1969 Social Security Number ***-**-**** MARRIED. Date of Birth MARRIED (504) 432-5665. Description of.

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