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Globe life insurance applicati... Globe Life And Accident Insurance Company Administrative Office: Globe Life Center, Oklahoma City, Oklahoma 73184 Group Enrollment Form for Accidental Death Policy Benefit Amount Payment Type $3,000

Earthquake cea application for... CALIFORNIA EARTHQUAKE AUTHORITY EARTHQUAKE INSURANCE APPLICATION INSTRUCTIONS POLICY EFFECTIVE DATE AND EXPIRATION DATE Provide CEA policy effective date and expiration date. CEA Earthquake Insurance Application Instructions 01/2012 Revision Earthquake Insurance Application Effective Date Applicant Information Applicant First Name Co-Applicant if applicable Last Name Middle Initial Number and Street Address City State Work Home Unit ZIP Code County Companion Policy Information Participating Insurer Type of Policy Homeowner Dwelling Coverage A Limit Renters Homeowners/Dwelling Fire Basic Program Rating Territory Year Built Construction Type Number of Stories in building Including Basement Is there unrepaired structural earthquake damage to the dwelling Frame Other Number of Chimneys Square Footage Foundation Type Roof Type Raised Slab Composition Tile Wood Shake Yes No If yes DO NOT BIND and explain in Remarks Dwelling secured to foundation Cripple walls braced with plywood or equivalent NOTE Inspections are required on all properties with existing non-structural i.e. cosmetic earthquake damage. Expiration date must be the same as the expiration date of the companion policy. APPLICANT Complete all requested information for applicant s including Name s Telephone number s Street address of physical location of insured property Mailing address if different from street address of property s physical location COMPANION POLICY INFORMATION Name of Participating Insurer Policy number of companion policy Dwelling limit i*e* Coverage A of companion policy if companion policy has dwelling limit Expiration date of companion policy Type of companion policy POLICY TYPE RATING AND COVERAGE INFORMATION Identify CEA policy type based on the type of companion policy as follows Homeowner Companion policy must be either a Homeowners HO-1 2 3 5 or 8 or equivalent Dwelling Fire building Landlord building or Mobilehome policy. o M anufactured Hom e M obilehom e Written on CEA Homeowner Policy form however requires unique rating information* Condominium i*e* Common Interest Development Companion policy must be a Condominium Unit Owners HO-6 or equivalent policy. Renters Companion policy must be a Renters HO-4 or equivalent Mobilehome tenant policy Dwelling Fire contents only or Landlord contents only policy. Complete all information requested under the applicable CEA policy type. Select desired CEA policy limits and coverage options. PAYMENT OPTIONS Select payment option Annual or Installments SEND BILL TO Select who should receive the bill Insured or Mortgagee ADDITIONAL INTERESTS Complete information requested for each additional interest including Type o Additional insured or o Loss payee Name and address Loan number if applicable REMARKS Include any additional remarks as needed* SIGNATURE Secure the applicant s signature on the application the date and time the application is completed* Provide the producer s name address and license number. Is the home reinforced by an earthquake resistant bracing system or installed upon an approved foundation system certified by the California Department of Housing and Community Development Water heater secured to building frame Option Two 75 000 AND Loss of Use Coverage D 25 000 50 000 100 000 No deductible for this coverage if Coverage A deductible is met.

Louisiana department of insura... L O U I S I A N A D E P A RT M E N T JAMES OF INSURANCE J. D O N E L O N COMMISSIONER INSTRUCTIONS FOR APPLICATION TO ACT AS A SPECIALTY INSURER IN THE STATE OF LOUISIANA GENERAL INSTRUCTIONS This

Accountants professional liabi... NAVIGATORS INSURANCE COMPANY ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after termination of this

Commercial automobiletruckers... National Casualty Company Home Office: Madison, Wisconsin Adm Office: 8877 Gainey Center Dr. Scottsdale, Arizona 85258 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio

Group life portability insuran... Standard Insurance Company Continued Bene?ts 800.378.4668 Tel 800.331.3397 Fax 920 SW Sixth Avenue Portland OR 97204 Group Life Portability Insurance Application INSTRUCTIONS PLEASE READ CAREFULLY

Travelsafe insurance bluecross... Blue Cross Center, 8000 Makati Avenue, 1200 Makati City, Metro Manila, Philippines Tel. No.: +63 2 899-8001 Fax No.: +63 2 899-5389; +63 2 325-0637 Email: travel sales bluecross.com.ph Website: www.bluecross.com.ph

2013 demonstration jump insura... Demonstration Jump Insurance Application 1) Terms: For each exhibition, a completed Demonstration Jump Insurance Application AND payment should be received at least 3 days before the intended jump

State of california department... If an active Public Insurance Adjuster qualification exists fees and signed renewal certification and Branch Office Certificate if applicable must be date your license expires. Insurance. ca.gov under Online Services. Check license type s you are renewing Current Fee AJ Adjuster Per Qualified Manager Branch Office Certificate ea Starting with June 2013 Renewals PJ Public Adjuster Renewal Application Certifications 1. If an active Insurance Adjust...

Utah health insurance applicat... UTAH SMALL EMPLOYER EMPLOYEE HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. REASON FOR ENROLLMENT mark all that apply New Group Newborn Loss of Coverage Open Enrollment Court Order Marriage New Hire Dependent Addition Divorce New Application Other Military Leave of Absence USERRA COBRA Utah mini-COBRA Length of continuation coverage 12 mos. Attach a separate sheet if necessary. Will coverage continue Employer group Governmental Name of Individual Insurer List policyholder name insurer name and phone number Spouse/Domestic Partner Page 1 of 3 Date of Coverage MM/YY Start Date End Date Type of Coverage Check all that apply Individual Medicare Other Utah Small Employer Health Insurance Application January 2014 E. ACKNOWLEDGMENT AND SIGNATURE I agree to abide by the insurer s enrollment provisions. 18 mos. 36 mos. Other Original Qualifying Event Date Qualifying Event Date Date of Event Effective Date New Hire Waiting Period WAIVER OF COVERAGE Individuals waiving coverage complete Waiver of Coverage. A. EMPLOYER INFORMATION Employer Is this a division Yes No If Yes name of parent company Name Last First MI Job Title Employment status Full-time Owner/business partner Retired Other Marital Status Legally Married Single Divorced Widowed Hrs/Week Hire Date / Rehire Date Domestic Partner Home Address Apt. City State Zip Mailing Address Home/Cell Phone Business Phone Email Address If you are American Indian or Alaska Native provide the state and name of your federally-recognized tribe C. ENROLLING EMPLOYEE / SPOUSE / DOMESTIC PARTNER / DEPENDENTS List yourself and all dependents applying for coverage. Attach a separate sheet if necessary. Name Last First Middle Social Security for insurer use only Date of Birth MM/DD/YYYY Spouse/ Dependent Check with your employer to determine if domestic partner coverage is available. Gender Male Female Tobacco Use Yes No D. CURRENT COVERAGE INFORMATION Please indicate for EACH person listed on this application any health care coverage Medicaid or Medicare currently in effect. This will be used to determine if benefits will be coordinated* Each person applying for coverage must be listed below. If no health care coverage is in effect indicate NONE* If coverage is provided for a dependent from a previous marriage or relationship please attach a copy of the court documentation that shows who is responsible for the dependents health care coverage so that the insurer can determine whose coverage is primary. I understand that coverage cannot start until after the waiting period. I authorize my employer to act as my agent in all matters of administration of the group program* I acknowledge that I have had the opportunity to waive coverage for myself and any eligible dependents. If the policy contains a voluntary arbitration provision ANY MATTER IN DISPUTE BETWEEN YOU AND THE INSURER MAY BE SUBJECT TO ARBITRATION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER RECOGNIZED ARBITRATOR A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE INSURER* THE INSURER SHALL BEAR THE COSTS OF ARBITRATION FILING FEES ADMINISTRATIVE FEES AND ARBITRATOR FEES* OTHER EXPENSES OF ARBITRATION INCLUDING BUT NOT LIMITED TO ATTORNEY FEES EXPENSES OF DISCOVERY WITNESSES STENOGRAPHER TRANSLATORS AND SIMILAR EXPENSES WILL BE BORNE BY THE PARTY INCURRING THOSE EXPENSES* ANY DECISION REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY.

Utah universal health insuranc... UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. Effective Date PEC New Hire Waiting Period REASON FOR ENROLLMENT (mark all that apply) New Group Newborn Loss of

Form flood insurance applicati... SIGNATURE OF INSURANCE AGENT/BROKER ANNUAL SUBTOTAL probation surcharge FEDERAL POLICY FEE TOTAL PREPAID AMOUNt Previously FEMA Form 81-16 PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM IMPORTANT COMPLETE PART 1 AND PART 2 ON LAST PAGE BEFORE SENDING APPLICATION TO THE NFIP IMPORTANT F-050 8/10 FLOOD INSURANCE APPLICATION FEMA FORM 086-0-1 NONDISCRIMINATION No person or organization shall be excluded from participation in denied the benefits of or subjected to discrimination under the Program authorized by the Act on the grounds of race color creed sex age or national origin. PRIVACY ACT policy. U*S* DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency National Flood Insurance Program O. M. B. No* 1660-0006 Expires August 31 2013 part 1 of 2 of flood insurance application Renewal important please print or type policy term DIRECT BILL INSTRUCTIONS BILL INSURED BILL SECOND MORTGAGEE BILL OTHER POLICY PERIOD IS FROM TO 12 01 A. M LOCAL TIME AT THE INSURED PROPERTY LOCATION Waiting period standard 30-day map rev* zone change from non-sfHa to sfHa one Day loan no waiting Lender Required No Waiting BILL FIRST MORTGAGEE BILL LOSS PAYEE name mailing Address and telephone no. of insured insured mail address agent s tax id fax no. is insurance required for disaster assistance If yes check the government agency sba other specify enter case file number yes fema no fha property location disaster assistance agent information Name Address of licensed property or casualty insurance agent or broker agency no. phone no. community 2nd mortgageE/ Other name and Address of first mortgagee loan no. Rating map information NAME OF COUNTY/PARISH COMMUNITY No*/PANEL No* AND SUFFIX FIRM zone COMMUNITY PROGRAm TYPE IS REGULAR EMERGENCY building contents construction data 3 or more split level BASEMENT ENCLOSure crawlspace NONE m anufactured mobile FINISHED basement/enclosure home/travel trailer on foundation crawlspace IF NOT A SINGLE-FAMILY DWELLING subgrade crawlspace THE NUMBER OF OCCUPANCIES UNITS IS BUILDING USE Main house/building Detached guest house Detached garage Agricultural building Warehouse Poolhouse clubhouse recreation building t ool/storage shed IS BUILDING walled and roofed IS BUILDING over water partially entirely IS BUILDING INSURED S PRINCIPAL RESIDENCE N F I P IS BUILDING elevated If yes area below is free of obstruction with obstruction if elevated complete part 2 of application ESTIMATED REPLACEMENT COST amount FOR MANUFACTURED MOBILE HOMEs/travel trailers complete part 2 section III. C O Y lowest floor above ground level and higher a bove ground level more than one full floor if single family contents are rated throughout the building If no please describe ALL BUILDINGS CHECK ONE OF THE FIVE BLOCKS and record corresponding date in the date box BUILDING PERMIT DATE MANUFACTURED MOBILE HOMES/travel trailers LOCATED IN A MOBILE HOME PARK OR SUBDIVISION CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION Facilities DATE OF CONSTRUCTION SUBSTANTIAL IMPROVEMENT DATE SUBDIVISION DATE OF PERMANENT PLACEMENT DATE // MM/DD/YYYY IS BUILDING POST-FIRM CONSTRUCTION IF POST-FIRM CONSTRUCTION IN ZONES A A1-A30 AE AO AH V V1-V30 VE OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED attach certification* Building Diagram Number lowest adjacent grade LAG Elevation certification date LOWEST FLOOR ELEVATION BASE FLOOD ELEVATION DIFFERENCE TO NEAREST FOOT OR IN ZONES V AND V1-V30 ONLY DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION IS BUILDING FLOOD-PROOFED SEE FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.

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