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❑❑IDD T❑❑❑❑ate❑®aDD❑❑❑d MMm❑d FF ❑❑D❑ 11DmmDOODDIMOE1 a-❑d 11=11 OFFFFIFTHIT❑FTPI❑ ❑am ate]❑❑maw❑D❑ID❑ID=mmFM❑111MEDIFM❑DO ❑❑[I]EIDI[DCIm❑[fl[ImID❑=❑d Or=1 gym❑❑m'FFF[❑111D❑❑ ❑❑ID❑m m❑T❑FFFFI]mad D-=❑❑IDm❑❑m'm❑d m❑m FFFm❑EIED[Iff�DE1❑1V❑TU❑m❑d D-M❑❑IDm❑❑m'm mID m❑mDE11❑m❑❑IDd❑❑❑d Or m❑❑DDI]Or❑❑❑Fm ❑❑L IMmQd❑D)❑ 111m❑❑m❑❑r❑Dd ad❑❑ad D-❑ FFn❑D ❑❑❑D❑❑❑m 11111❑❑m❑❑m❑®mo E11111 111m❑❑m❑ ❑❑m OOOEE Or FIMII=m❑❑mom❑❑d ad m❑d Or❑IDmD D'❑❑d❑d 1111❑d D FUMM DDD'❑❑❑111 a FFM ❑❑m 1111111111 D-110❑FMM❑❑❑❑D❑m m EM❑❑"m❑T❑mID❑❑ 5. Cancellation ❑lidEr=❑FFflDEr❑❑m 110D•❑1FMFFflmIDDIDDFFM a. -❑❑❑ [I= ❑D❑❑d❑ DDD'd❑ m❑❑❑❑ 11111 110❑❑ ❑❑❑®Dm]❑❑lid DIDDD'lid Fri❑Dm11 Ell]r®❑1E D❑a❑r❑m❑FM 11DDI7❑mmD=❑1FFFMmo❑FFFFT❑❑ ❑m m❑❑❑ ❑m D-❑ 011101 m ❑❑m"m❑1V❑mID❑❑ D-d 1111E 11111D m❑D A m❑mm r DID❑❑❑❑mOm110 ❑Dd Cr DID❑❑ EErOOEE1'mIID❑mid DD❑D}❑❑❑❑❑d ED m❑D7EFFF❑DID r❑❑D D=d[Er SOD❑mDDm❑111❑1nd IlEr ❑M ❑ DFU❑❑zFzTr❑❑❑m=❑a:7 m❑1fl❑FFF1fl❑m❑dOr=❑❑ b. ❑ ❑❑❑❑m DDDm111 ADD❑❑ ❑m❑❑FFM❑❑D-❑ [EEr-DEl' ❑❑❑❑d ED d❑1111E FM❑❑1D❑=❑❑1r=O❑❑d E1EE11r d❑❑r®❑❑ D❑HOEUDMO❑mmDFFM❑MMO 8. Other Insurance (1) ❑❑❑d❑DZ]❑❑Dr❑❑ =❑❑ ❑FDA❑d❑[111❑ ❑O] a. CD LE]r❑❑m DD DDd F-M❑®❑❑ED m❑mmE[E]❑FTM ODUDELITIr E111❑❑❑❑m❑❑❑IDS D==Ir[E❑IE❑❑m❑❑❑m❑O]Fill]❑=D-❑111m❑❑mom D'❑❑D❑HTED ❑❑❑MEr[❑r1]Or FM ❑FFF1❑❑❑gym❑m❑m (2) ❑❑❑d❑Dm ❑❑❑r❑❑ ED❑❑ ❑FFM El dD®D mD FMm❑❑m❑m❑DM[IME❑ram❑❑❑m❑DD IDm❑DD❑ m❑m❑DH❑❑FF[n 111111 mDZIM❑r❑❑❑D7 111MD-11 ❑7MID❑DD'❑mDJdrMF r❑❑m❑❑7 ❑ ❑❑❑❑❑7ME❑❑7'❑❑m❑DD❑DmD7IDFFM❑❑❑mDd❑ c. ❑ ❑m FTM❑ME]d❑=r E[]D'm[IFTU=F MIIFT MDO] 1E1DD'Dr d❑❑7❑d DOE❑m❑Dmd Or EME11❑ Ed❑DmED 111111❑d 1Emr d DFFFFFFM❑m III[Ad r❑DEE11]❑❑❑ 11 111D❑m FqM❑m❑❑mod==[]=Q-r d 111Er 11IFF11 d. ❑❑DID❑❑❑7m❑m❑DFFM❑❑❑FD❑]❑❑❑7❑❑❑FFM 11 b. ❑ ❑❑❑❑❑7❑D❑EEKIDm❑DD❑DmD1]❑DD'❑11❑7❑-❑ d❑❑Ell=[Immm❑❑ID❑❑m❑ Or[lid m❑71id❑ ❑]❑D'❑❑m❑D Dm FgM[I ❑DIDD-DmD-❑m❑ZID❑❑ ❑ODm❑Dd❑❑IE "❑DID[1❑]❑]❑DID❑E1'❑m❑FFn❑ 1jd FFFMO 11 EL❑7 e. ❑❑ MED11 ❑mmDd DID❑❑l] ❑d DID❑®FM (1)❑❑❑❑❑ HOME 11111111110 110111111 ❑❑D mD❑❑❑11DD D ❑❑❑lid❑❑❑7'lid❑7❑DID'11111111 Id❑❑❑dA❑❑ ❑❑ ❑]❑E❑❑mDD[Old❑❑❑m❑?❑❑011117FM1111❑71111 m❑❑❑❑❑ID❑r❑❑7Dd m DM❑❑D-❑Cr❑❑❑ID❑ID❑❑IY]DII] ❑❑m❑m❑❑❑7❑OOMIDD'❑❑m❑D'❑❑d❑d❑[Dd Or❑ ❑❑❑lid❑D❑T lid❑m❑m❑IMMIDEr❑❑lid❑❑❑m❑❑❑ -F-]=❑DD'❑mD Or❑❑l❑dFF ❑Dz7110111111 Or 111r❑1D❑7❑❑❑❑m❑mmDm❑❑❑mID❑❑❑ ❑11FFT ]DJm❑®❑DJ❑mD1❑DID❑d❑QD EL®-d Ell] - (2) =❑❑❑ID110DDDD1Ed ad❑DII➢❑m❑d F-MFFIMMEE]r d❑ r❑❑❑d❑7 ❑ ❑❑❑❑I❑❑d Or OFFF[❑7D-FFFfl❑rD❑m❑7 f. i❑❑❑[❑IDDmD❑Olrid ED Or DEEM Eld]D❑®❑❑D®❑❑❑ 9• Premium Audit m ❑❑m-❑❑IM❑m❑❑ID❑7 a. _ ❑❑ ❑C Z]❑❑= ❑mD Ir❑❑110❑m ]Ir❑ EE❑D 6. Changes ❑❑❑L]r❑❑❑❑❑D-FFniii❑❑❑ Erd❑❑m❑❑mD❑❑DtD-❑[I]m ❑❑d IV❑❑7= 11117❑❑❑❑m❑❑❑❑d 111]mm❑❑7'❑❑]❑❑❑7111111]D7❑❑m❑ ❑ b. =❑I❑❑❑=ad❑❑❑❑]❑M❑❑]❑❑❑O]❑ 110❑FF111 D❑ 7d❑d DID❑❑MIMFM❑❑❑d DIDmr❑d❑❑❑❑DEt DDd❑7m ❑MED❑DD'❑❑❑m Or❑ EEL]d m❑m❑D'❑❑❑11 DIED =110D-F1FnD7'1jd❑❑❑❑7❑m❑1]❑❑❑❑D❑d❑❑ID❑❑ID'❑❑❑❑ d❑❑❑DI❑D'❑❑❑]❑❑❑❑❑ []=111]❑❑❑❑m❑❑❑]❑❑❑❑❑ FFn❑z] ❑❑m❑❑❑❑ ❑J EE ❑m❑ ❑J O m❑m❑FFFn ❑❑❑D ❑❑d mD❑D-❑]d ED❑❑❑❑mID m❑11111111111101111❑D-❑d❑ ❑❑DD'101117 D-❑1❑m❑=1117❑m❑❑❑d❑d QD'❑7❑DDd❑ Or 111111011 EEt=[I❑❑D-❑]d❑7Dd❑17Dd❑D=DIDDID❑❑ ---1--F-d D'm❑1111E ®D❑l❑D❑❑d❑❑7❑D'❑d❑7❑❑❑❑d❑❑❑d❑❑1I[E ❑❑❑d FF[n Or❑❑11011❑❑❑❑[lid D❑IM]❑D❑❑0=111d[❑Cd❑❑7❑7❑❑ 7. Maintenance Of/Changes To Controlling ED❑mom❑Dm❑m❑ I]Eljdm❑mmadm❑dFFF1 Underlying Insurance Or DO Ill Q❑7DCd❑ID-❑IDDmD Or[lid 111][Ir D ❑CD=" j =r❑FFFM❑❑❑❑dOr❑I❑❑❑❑fir ❑❑DD]❑❑❑ EMOOFTITIODElEr Elid EEr❑❑[Ell]=11❑❑11111r 111Er11=1111 ❑1111WILLad❑❑]❑❑]F[fl❑❑❑=❑FFF❑❑�W r❑d❑=1111 1117 ❑❑Z] ❑❑mD❑❑❑❑lid❑❑❑7r❑d❑❑ D7DD❑❑❑❑D-❑mD DID❑Dm❑❑7 Dr❑❑Dllr❑d❑DII➢[I❑❑❑7 c. ❑❑❑®Dm]❑❑❑d=EE: ❑d m❑DIDI]11IF❑❑7rd FH11E 111]D'111117❑I❑❑IIID❑7❑17d1111m❑7❑❑❑❑❑❑d'11D❑II➢DZ FF❑❑ ❑IMrO❑FFM❑❑ ❑❑❑ ❑❑❑d❑ DID D-❑❑❑]❑❑ D❑]mm❑"m❑T❑FTF❑❑❑Dd D'DIm❑❑❑]D7❑❑❑EI'❑EDOM] D7❑❑❑❑7FFFfl❑❑❑❑d❑I]❑d❑=1111]D❑]❑IIDm❑II➢❑m r❑mDID T❑❑❑"❑❑r m Or❑d❑❑❑❑1T❑❑11❑❑=❑❑7❑D ❑FTE D❑]DDW❑❑❑❑DM ADD'❑❑m❑7❑❑1111= Page 4 of 5 11 MMEE-r DOE11110 Or DEFITF MMFMM IIDI❑❑❑= CX 00 01 04 13