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

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1 APPLICATION DETAIL Insured RIGOBERTO POLANCO AND JULISSA POLANCO Effective-Expiration Policy Number Form Program HB3 BEACON AGENCY INFORMATION Agency Number Agency Name Address NANCY L. HOFFMAN P O BOX 486 City, State Zip WESTWEGO, LA Phone Number (504) APPLICANTCO-APPLICANT INFORMATION Applicant Name RIG POLANCO of Birth Co-Applicant Name of Birth JULISSA E POLANCO Social Security Number ***-**-**** Social Security Number ***-**-**** Marital Status MARRIED Marital Status MARRIED Home Phone (504) Home Phone (504) Cell Phone Cell Phone Work Phone Work Phone Address Address Preferred Contact Preferred Contact Number HOME Number HOME Passport Number Passport Number EMPLOYED HOMEMAKER Years Present Job 25 Years Present Job 10 Description of PROJECT MANAGER Description of HOMEMAKER 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 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 624 SAINT JULIEN DR Address 624 SAINT JULIEN DR Option Line KENNER, LA JEFFERSON City, State Zip 0 KENNER, LA LPIC HOAPP

2 BASIC COVERAGE LIMITS AND PREMIUMS Coverage Coverage A - Dwelling Coverage B - Other Structures Coverage C - Personal Property Coverage D - Loss of Use Coverage E - Personal Liability Limit $252,000 $25, $126,000 $50,400 $300,000 Coverage F - Medical Payments $1,000 DEDUCTIBLES All Other Peril (AOP) Deductible Calendar Year Named Storm Deductible % Calendar Year Named Storm Deductible Dollar OPTIONAL COVERAGES, DISCOUNTS, FEES AND SURCHARGES Coverages Limit Coverages $2,500 2% $5,040 Premium $5,524 Building Additions and Alterations Dwelling - Increased replacement Cost Coverage B - Specific Structure Coverage C - Replacement Cost YES $35 Selected Description: Coverage C - Special Personal Property Other Structure Rented To Others Ordinance or Law - 15% 25% YES Description: Other Members Of Your Household Golf Cart Physical Damage Description: Description: Permitted Incidental Occupancies - Residence Home Computer Description: Description: Unit Owners Coverage A - Special Coverage Unscheduled Property - Jewelry $1,500 Unit Owners Rented To Others Unscheduled Property - Ware $2,500 Scheduled Personal Property Water Back Up and Sump Overflow $5,000 Refrigerated Personal Property($100 deductible) YES Animal Limited Liability - Coverage E Personal Injury Coverage F Residence in Trust Loss Assessment Increased Limit $1,000 Permitted Incidental Occupancies - Structures Identity Fraud Expense $25,000 Description: Discounts Applied Discounts Applied Book Transfer Protective Device - Burglar YES Claim Free 3 yr 5 yr Protective Device - Fire YES Golden Age Protective Device - Sprinkler IBHS Fortified Renovation New Purchase Secured Communities Non-Structural Hail Loss Limitation Wind Mitigation - Complete Preferred Builder Wind Mitigation - Hip Roof YES Protective Device - Package Wind Mitigation - Building Code Fees Surcharges Fixed Expense $60 Distance To Water Inspection $25 Experience Rating Factors Citizens FAIR Plan Assessment $150 No Prior Insurance Total Fees Seasonal Home LPIC HOAPP

3 PREMIUM Subtotal (Basic Coverage, Optional Coverages, Discounts) Total Fees Total Premium $4,007 $235 $4,242 PRIOR CARRIER Company ASI Prior Insurance Expiration FLOOD INSURANCE Company HARTFORD Policy Number Policy Number LAL38654 FD2013 LOSS HISTORY X None of Loss Loss Description Type of Loss Amount of Loss DWELLING INFORMATION Building Type Construction Type Year of Construction Number of Stories Occupied By Inside City Limits Roof Type Primary Heat System Number of Families Type Of Wiring Firewalls between units Market Value MASONRY VENEER Story OWNER <7 Miles to Fire Station 7 miles or less Years At Residence Dwelling Condition DWELLING REVATION SINGLE FAMILY DWELLING SHINGLE-COMPOSITION CENTRAL HEATAIR 3 1 $250,000 Territory 125 Flood Zone Square Footage Protection Class Occupancy 1,000 ft or Less to Hydrant Responding Fire Department Number of Units Secondary Heat System Number of Rooms 8 Number of Occupants Foundation Type of Plumbing Type of Siding Replacement Cost Type PartialComplete Year Renovated Comments Roof COMPLETE 2010 Electrical COMPLETE 2010 Plumbing COMPLETE 2010 HeatingAir Conditioning COMPLETE 2010 Exterior Paint COMPLETE 2010 POLICY INTEREST Type Name and Address Interest MORTGAGEE UNDERWRITING INFORMATION AE 2 1,900 PRIMARY 1000 Feet or Less STATION 39 NE SLAB $252,000 1ST MTG BANK OF AMERICA NA ISAOA ATIMA Bill To YES PO BOX Loan ID FORT WORTH, TX Phone # Fax # 1 Is there any business conducted on the premises, including home day care? 2 Do applicants have any resident employees? 3 Is the dwelling built partially or entirely over water or accessible by boat only? 4 Is there more than one residence on the premises? LPIC HOAPP

4 LIGHTHOUSE PROPERTY INSURANCE Has coverage been declined, cancelled or non-renewed during the last 3 years for reasons other than non-payment of premium or exposure reduction? Explain. Has applicant had a foreclosure, repossession or bankruptcy during the last 5 years? Are there any farm animals or exotic animals on premises? 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? If a dog, was it trained as guard or attack dog or used in military or police work? Does it have a bite history or caused bodily injury to any person? Is it a breed historically bred for fighting? 10 Is dwelling located on more than 5 acres? if yes, describe land use Is residence located on a farm or ranch or is there any farming or ranching activities on premises? Does the applicant own any recreational vehicles (jet skis, snowmobiles, dune buggies, mini-bikes, ATV's, etc? 13 Is house for sale? 14 Applicant has never been canceled or non-renewed for material misrepresentation, insurance fraud or convicted of arson? 15 Is the dwelling under construction or undergoing major renovation or extensive remodeling? If yes, please explain and provide estimated completion date and dollar value. 16 Is the dwelling located on or near commercial property? 17 Was the structure originally built for other than a private residence and then converted? 18 Is there any existing damage to dwelling or other structure? 19 Does dwelling have stairways with 3 or more steps or porchesdecks are over 2 ft off the ground? If yes, does it have handrails? Are there any skateboard ramps or bicycle ramps? Is there a trampoline on the premises? Is dwelling located on a paved roadway? Is dwelling visible from the road and to neighbors? Was the dwelling built by a licensed contractor? Is there a swimming pool on the premises? If yes, inground or above ground?inground If yes, is it fenced? Is there a diving board? Is there a slide? Is it empty? 27 Is property owned by a trust? 28 Is there an underground fuel tank on the premises? 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. YES YES SPECIFIC COVERAGE EXCLUSIONS I understand the insurance policy I am applying for contains the following exclusions. This means the Company will not pay for any damage or amounts I become liable for and will not defend me in any suits brought against me resulting from alleged injury or damage caused by any of these items I own or keep. Trampolines Diving boards and pool slides Jet skis and similar watercraft Day care of any type Earthquake, Earth movement Recreational Vehicles Any animal I own or keep unless I have Animal Limited Liability Coverage. LPIC HOAPP

5 STATEMENT OF CONDITION Applicant s initials below confirm the validity of the following statements: No applicant has ever been canceled or non-renewed for material misrepresentation, insurance fraud or convicted of arson. The dwelling, other structures and personal property insured under this policy have no unrepaired damage, including hurricane or flood damage. Property to be insured is not located in a known sinkhole, pollution, landslide, cave-in area or located outside the protected levee system. During the term of or any renewal of this policy, the insured premise or any portion of the insured premises will not be rented to others unless the Company is notified immediately. ANIMAL LIMITED LIABILITY COVERAGE I have elected to purchase animal limited liability coverage at limits of $25,000 for Coverage E - Personal Liability and $1,000 for Medical Payments To Others. This is the most the Company will pay per occurrence and per policy period for alleged injury or damage caused by or originating from any animals I own or keep. I also understand this coverage does not cover losses caused by or originating from the following list of prohibited dogs: Akita American Pit Bull Terrier Catahoula Leopard Coyote Presa Canario Rottweiler Wolf or Wolf Breed Any dog breed historically bred for fighting Any dog with a prior history of biting or attacking persons, property or animals American Bulldog American Staffordshire Terrier Chow Doberman Pinscher Pit Bull Terrier Staffordshire Terrier Any mixture, including prohibited dogs Guard dog or attack dogs, including military or police dogs Any dog that has not had inoculations as required by law Any dog owned or kept by any insured at the time of the application, but not disclosed on the application LIMITED WATER DAMAGE COVERAGE I understand this policy has a $10,000 limit of liability for losses caused by water damage. I understand this limit applies to all damage or expenses I incur under Coverage A - Dwelling, Coverage B - Other Structures and Coverage C - Personal Property combined. This applies to any home over 40 years old if the plumbing system has not been updated since LPIC HOAPP

6 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. Time Co- Time AGENT'S SIGNATURE A copy of the application has been furnished to the applicant or insured and coverage is: Bound effective () (Time) AM PM Not Bound Agent Signature Agent Number BILLING INFORMATION Initial Payment By Insured Bill To At Renewal: MORTGAGEE Payment Options Available: X 1 -Pay 2 -Pay 4 -Pay Installment Fee: Make Checks Payable to LIGHTHOUSE PROPERTY INSURANCE and write policy number on your check. $0 LPIC HOAPP

7 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 IBHS Fortified For Safer Living discount - copy of the IBHS certificate which is presented to home owner upon completion of construction. Submit to company. New Purchase Discount - proof of closing submit to company 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. Seasonal - Name, address and phone number of Professional Management firm or name, address and phone number of reliable friend, neighbor or relative. Submit to company. 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 HOAPP