		HOMEOWNERS POLICY APPLICATION

PROPOSED ON: 05/13/2003		PROPOSAL NUMBER: 318

MAILING ADDRESS:		SERVICE CENTER: 58 AGENT: 3143
GLENN SMITH N7907 STATE HWY 81 WATERLOO NY 53595		STEPHEN MILLER 104 W LAKE SHORE BLDV LADYSMITH NY 54848 OFFICE: (715) 542-6732

TERM LENGTH: 12 MONTHS		EFFECTIVE: 05/30/2003

NAMED INSURED:
GLENN SMITH N7907 STATE HWY 81 WATERLOO WI 53595

SUMMARY OF COVERAGES & PREMIUMS
PROPERTY & LIABILITY COVERAGES		PREMIUM
Property Coverages
	Dwelling	$943
	Other Structures	Included
	Personal Property	Included
	Loss of Use	Included
Liability & Medical Coverages
	Personal Liability	$8
	Medical Payments to Others	$2
Optional Coverages
	Miscellaneous Endorsements	$428
	Watercraft	$193
	Recreational Vehicle	$405
	Personal Umbrella Liability Coverage	No coverage

TOTAL POLICY PREMIUM		$1,979

LOCATION 1

N7907 STATE HWY 81
WATERLOO NY 53595
Protection Class 9

Coverage at the described location is provided only where a limit of liability is shown or a premium is stated.

DWELLING
RM3 - DWELLING AND PERSONAL PROPERTY COVERAGES - COMPREHENSIVE FORM
Property Loss Deductible $250
RM-290 Personal Property Replacement Cost
RM-184 Automatic Value-up
RM-216 Premium Credit for Protective Devices

Coverages			Limit of Liability	Premium
	A. Dwelling		$197,763	$943
	B. Other Structures		$19,776	Included
	C. Personal Property		$98,882	Included
	D. Loss of Use		$39,553	Included
	E. Personal Liability	Each occurrence:	$300,000	$8
	F. Medical Payments to Others	Each person:	$1,000	$2
Miscellaneous Endorsements
	RM-48 Increased Coverage on Other Structures		$6,000	$14
	RM-56 Use of Woodburner on Premises			$50

CONDOMINIUM
RM9 - CONDOMINIUM UNIT-OWNERS COVERAGE SPECIAL FORM
Property Loss Deductible $500
RM-290 Personal Property Replacement Cost

Coverages			Limit of Liability	Premium
	C. Personal Property		$20,000	Included
	A. Dwelling		$2,000	Included
	D. Loss of Use		$8,000	Included
	E. Personal Liability	Each occurrence:	$300,000	Included
	F. Medical Payments to Others	Each person:	$1,000	Included
	Theft Loss Deductible - $250.00			Included

TOTAL PREMIUM - LOCATION 1

$1,017

WATERCRAFT
BOAT - WATERCRAFT
Property Loss Deductible $0

Coverages		Limit of Liability	Premium
	BT-20 Watercraft - Liability	$300,000	$24
	Watercraft Trailer Physical Damage	$1,500	$14
	Watercraft Medical Payments	$1,000	$5
	Uninsured Motorist Watercraft	$300,000	Included
	Underinsured Motorist Watercraft	$300,000	Included
	BT-60 Watercraft - Physical Damage	$10,000	$79
	Watercraft Motor Physical Damage	$8,500	$71
Description of Watercraft Year: 1997 Length:18 Type:O - OUTBOARD BOATS & PONTOONS Serial:DJASDLKK

RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

Coverages		Limit of Liability	Premium
	RV-20 Recreational Vehicle Liability	$300,000	$36
	Recreational Vehicle Medical Payments	$1,000	$2
	Uninsured Motorist Recreational Vehicle	$300,000	Included
	Underinsured Motorist Recreational Vehicle	$300,000	Included
	RV-60 Recreational Vehicle - Physical Damage	$2,500	Included
Description of Recreational Vehicle Year: 1994 Length: Type:SN - SNOWMOBILE Serial:

RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

Coverages		Limit of Liability	Premium
	RV-20 Recreational Vehicle Liability	$300,000	$36
	Recreational Vehicle Medical Payments	$1,000	$2
	Uninsured Motorist Recreational Vehicle	$300,000	Included
	Underinsured Motorist Recreational Vehicle	$300,000	Included
	RV-60 Recreational Vehicle - Physical Damage	$3,000	$99
	Trailer Physical Damage	$1,000	$30
Description of Recreational Vehicle Year: 1995 Length: Type:SN - SNOWMOBILE Serial:

RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

Coverages		Limit of Liability	Premium
	RV-20 Recreational Vehicle Liability	$300,000	$33
	Recreational Vehicle Medical Payments	$1,000	$2
	Uninsured Motorist Recreational Vehicle	$300,000	Included
	Underinsured Motorist Recreational Vehicle	$300,000	Included
	RV-60 Recreational Vehicle - Physical Damage	$5,500	$165
Description of Recreational Vehicle Year: 2001 Length: Type:SN - SNOWMOBILE Serial:

CONDOMINIUM
RM9 - CONDOMINIUM UNIT-OWNERS COVERAGE SPECIAL FORM
Property Loss Deductible $500
RM-290 Personal Property Replacement Cost

Coverages			Limit of Liability	Premium
	C. Personal Property		$20,000	Included
	A. Dwelling		$2,000	Included
	D. Loss of Use		$8,000	Included
	E. Personal Liability	Each occurrence:	$300,000	Included
	F. Medical Payments to Others	Each person:	$1,000	Included
	Theft Loss Deductible - $250.00			Included

Miscellaneous Policy Coverages

Miscellaneous Endorsements

Coverages		Limit of Liability	Premium
	RM-61 - Scheduled Personal Property - Fine Arts, Glass, Porcelain & Ceramics (Non-Breakable)	$11,535	$127
	RM-61 - Scheduled Personal Property - Guns	$13,000	$182
	RM-61 - Scheduled Personal Property - Jewelry	$5,475	$55

1 LOSS PAYABLE CLAUSE-AUDIO, VISUAL & DATA ELECTRONICS EQUIPMENT PREMISE 1

LEASE CORP AMERICA
340 E BIG BEAVER RD
TROY NY 48083

General Risk Selection

(1) Have you been rejected, cancelled or non-renewed?

Explain:

(2) Have you had liens, judgements, foreclosures or bankruptcies in the past 3 years?

Explain:

(3) List all prior losses or claims on this or other property:

(4) Are any other business operations owned or operated from your premises ?

(5) Any evidence of mold or prior water damage in buildings ?

Explain:

(6) Have you obtained certificates of insurance from tenants ?

(7) Has the insured been insured with TRITECH in the last 6 months ?

(8) Do you have a formal safety program for your business ?

(9) Is all business conducted in the State ?

(10) Do you have a dog ?

Breed:

(11) Any bites, scratches or incidents with the dog ?

(12) Is there a trampoline ?

(13) Do you heat your dwelling or any building with wood ?

(14) Do any unrelated adults reside in your household ?

SIGNATURES

The undersigned hereby agrees and represents that:

a) This application contains a full and true description and statement of the condition, situation, value, encumbrance, occupancy and title to the property to be insured with TRITECH Insurance Company to the best of my knowledge.
b) The answers to the questions and statements made are true.
c) Notification will be given to the agent of any changes(s).

NOTICE OF INSURANCE INFORMATION PRACTICES:

Personal information about you may be collected from persons other than you. Such information as well as consumer reports which may include credit information, collected by us or our agents, may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent for instruction on how to submit a request to us.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject the person to criminal and civil penalties, including recission of coverage.

APPLICANT’S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true.

X Applicant’s Signature ____________________ Date __________ Agent’s Signature __________________

PROXY

The agent should have applicant read and sign the following designation:

The undersigned hereby appoints the Company, Cooperative, by any representative designated by its Board of Directors, attorney in fact for me to vote and act as my proxy at any meeting of policyholders of the TRITECH Insurance Company hereafter held, not attended by me in person, granting said attorney full authority to act for me in the transaction of any business coming before such meeting.

X Applicant’s Signature ____________________

TRITECH INSURANCE COMPANY

HOMEOWNERS POLICY APPLICATION

General Risk Selection