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Question 17 may be answered YES or NO. If YES is selected the license, jurisdiction and category section must be completed; once the application is submitted underwriting will review for eligibility.

17. Do you have a contractor's license?..................................................

................................................................................

YES

NO

If yes, please provide the following information:

License #

_____________________

Jurisdiction

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Category_____________________

2nd LOCATION UNDERWRITING QUESTIONS:

If a second location has been added to page 1 of this application, please complete the following questions. Please note: Risks may store BPP at a second location, but may not operate their business from a second location; other than a secondary residence.

Store front locations are not eligible.

1. Do you operate your business from a store front location?............................................................................................... YES 2. Do you rent or own a second residence?........................................................................................................................... YES 3. Do you have a partner that works directly from their own residence? (Note: If more than two owners must contact

NO NO

RLI for approval to add additional location.).................................................................................................................... YES 4. Do you rent or own a storage unit (maximum size: 250 sq ft.)?........................................................................................ YES 5. Do you store BPP in an outbuilding located more than 100 ft. away from your residence? (Note: an outbuilding

NO NO

within 100 ft. from your residence does not need to be added as a 2nd location)............................................................. YES

NO

OPTIONAL

Do you belong to a trade association, regularly visit a website, or receive a publication related to your Home Business? Please provide name and/or website address.

________________________________________________________________________________________

APPLICANT'S STATEMENT:

IMPORTANT: The statements (answers) given above are true and accurate. The applicant has not willfully concealed or misrepresented any material fact or circumstance concerning this application. This application does not constitute a binder.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties. (Not applicable in LA, MD, NM, OK, PA, TN, VA, and WA.)

MD: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

LA, NM: 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 (NM: civil fines and criminal penalties).

OK: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

PA: Any person who knowingly and with intent to defraud any insurance company or other person 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 subjects such person to criminal and civil penalties.

TN, VA, WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL SIGNATURE.

Date:

_______________________________

Applicant's Original Signature:

___________________________________________

Date:

_______________________________

Producer's Signature: ____________________________________________________

Agent's License Number: ________________________________________________ (Required if the Applicant resides in the state of Florida.)

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT

NO INSURANCE WILL BE IN EFFECT UNTIL RLI INSURANCE COMPANY ISSUES A POLICY.

Page 3 of 3 Pages

HBP 108 (04/09)FL

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