New , Renewal No.
Named Insured and P.O. Address (Number, Street, Town or City, County, State, Zip Code)
Bound :Yes No
Quote Only:Yes
STANDARD DELUXE POLICY
Policy Period: Fromto 12:01 a.m. Standard Time

The Described Location covered by this policy is located at the above address, unless otherwise stated.

Loc. / Bldg. / Prot. / Const. / Occupancy / Situated / Zip Code
Locatedfeet from hydrant, miles from Fire Dept.
Property Coverage / ACV or
Replacement
Cost / Deductible / Amount of Insurance
Loc. No. / Bldg. No. / Bldg. No. / Bldg. No.
Cov. A - Building(s) / $ / $ / $
Cov. B - Business Property / $ / $ / $

PROGRAMINSURED IS

Apartments Office Motel Owner Occupant

Mercantile Church Club Lessee (Tenant)

Service Lessor (Landlord)

Apartments ar Motel: # of Units

COVERAGE FORMSBuilding: SF-1 SF-2 SF-3

Contents: SF-1 SF-2 SF-4 SF-4A

PROPERTY COVERAGES – OPTIONAL INCREASES (Indicate Additional Amount)
Accounts Receivable$
Additional Expense$
Building Inflation Protection % per quarter
Employee Dishonesty$
# of Employees
Extender Endorsements
SF-513 SF-519
SF-514 SF-520 (Motel Extender Only)
SF-515 SF-500
Exterior Signs$
Loss of Income SF-312 Applies
Annual Receipts and/or Rents$
# of Additional Months
Money & Securities$
Outside GradeFloorBuilding Glass (SF-78)
For eachpane of glass, list the largest dimension:
(1)(2)(3) (4) (5)
For additional panes, attach schedule with longest dimension
for each pane.
Lettering or Ornamental Work Yes No / Refrigerated Food Products (SF-93)$
Sprinkler Leakage Yes No
Storekeepers Burglary & Robery (SF-58B)
$500 $1,000 per agree.
Other $
While Away From Insured Premises
Additional 10% increments
Valuable Papers & Records$
Other Optional Coverages – Describe
LIABILITY COVERAGE
Liability Coverage / Limit of Liability
Cov. L – Bodily Injury & Property Damage / $ Each Occurrence / $ Aggregate
Cov. M – Premises Medical Payments / $ Each Person / $ Each Accident

FORM OLT (LS-1) CGL (LS-5)Business Exclusion LS-70 Mandatory form on LS-5 Coverage.

OPTIONAL LIABILITY COVERAGE
Additional Insured Interest Name
Address
(To add more additional insureds see page 2)
Employees’ Non-Owned automobile $500,000 Maximum LimitCoverage Amount $
File Legal – Maximum $100,000
Personal Injury

Agents Code # MORTGAGEE NAME & ADDRESS

UNDERWRITING QUESTIONS MUST BE FULLY ANSWERED
Business of Applicant Other Occupancies
Protective Devices / Alarms (explain)
Is there coverage currently in force? Yes NoAny other policies with Security Mutual?
Current or Prior CarrierIs this account new to your office? Yes No
Is the current carrier offering a renewal? Yes NoPolicy #
Any losses to either the Insured or this location within the last 5 years? Yes NoIf so, explain
Has any carrier cancelled or non-renewed coverage in the past 3 years? Yes NoIf so, explain
Is Business seasonal? Yes NoYears in Business
Year of Construction Type of Roof – FLAT or SHINGLE? Number of Floors
Year of Electrical Year of Plumbing Approximate Square Footage
Year of Heating Type of Heating System
Dates and Types of Improvements
Adjacent Exposures N S E W
Approximate Distances N S E W
Any Cooking? Yes No
Is there any Fire Suppression system? Yes NoLast Inspected
Describe type of cooking equipment
Does the insured have a deep fat fryer? Yes No
Is the insured responsible for parking area? Yes No
Type of merchandise
Annual gross sales, receipts or rents$
Any product sold under own brand or label?
Any residential occupancy in bldg (If applicant is the building owner)? Yes NoIf so, number of units
Pool and/or Beach Front on premise? Yes No(If Diving Board Do Not Bind.)
Trampoline of premise? Do Not Bind Yes No
Any athletic teams sponsored? Yes NoType
Telephone Number and Contact for Inspection
Additional InsuredInterest Name
Address
Additional InsuredInterest Name
Address

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

Agency Name & LocationInsured’s Signature

Agent's Signature

Date

Page 1Ed. 2/08

SECURITY MUTUAL INSURANCE COMPANY
Privacy Protection Policy

Information Collection

We collect and use information about you in order to provide you with insurance and other services.

We obtain most of the information from you, primarily from the application you complete when you apply for our products or services.

Transaction Information: This is information about your transactions with us, our affiliates, or others. It includes your insurance coverage selections and premiums, payment and claims history, and information necessary for billing and payment. It may also include additional information used to adjust, investigate, and settle insurance claims, such as witness statements and police reports. Transaction information may be disclosed as described below.

Consumer Report Information: This is information we receive from a consumer reporting agency, and is used to confirm or supplement application information. It includes motor vehicle reports and/or claims history reports. We will disclose consumer report information only as necessary to quote or service your insurance policy and as permitted or required by law. To underwrite your insurance and provide an accurate insurance quote, consumer report information may be shared with our affiliated insurance underwriting association. By obtaining a quote or applying for insurance with us, you consent to our sharing of this information with our affiliated insurance underwriting company.

Information Protection

To guard your personal information, we maintain physical, electronic and procedural safeguards that comply with state regulations. We have also appointed a corporate privacy officer to monitor compliance with the Company's privacy policy.

All employees are required to protect the confidentiality of our customers' personal information, and they may not access that information unless there is a legitimate reason for doing so, such as responding to a customer request.

Information Disclosure

We will not sell your personal information.

We will not disclose your personal information except as necessary for conducting business or where permitted by law. For example, we may disclose your personal information to your agent, our employees or our service providers so they can service your business or respond to your questions or requests. We require the recipients of such information to protect the information and use it only for the purpose provided.

Future Notification

Each year, we will provide you with a summary of our privacy policy.

For More Information

If you have any questions about Security Mutual's privacy policy, please contact us or write to our privacy officer at Security Mutual Insurance Company, Post Office Box 4620, Ithaca, New York 14852-4620.

SMIC PRIVACY NOTICE6/2001