State Farm Fire and Casualty Company Applicant Name: CHACON, JORDAN

Binder Effective Date: 12-10-2021

GA Renters
Application / Binder-Receipt 11-G1-S778-0

NEW BUSINESS
APPLICANT: CHACON, JORDAN CO-APPLICANT: CHACON, SCARLETT
MAILING ADDRESS: 1539 HILLARY COVE CT PROPERTY LOCATION: 3300 COUNTRY CLB VLG LN APT F
LAWRENCEVILLE, GA 30043-7419 NORCROSS, GA 30092-4423
BILLING:
Put application on SFPP: Yes

COVERAGES / PREMIUM SECTION:

Type: RENTERS Policy Deductible: 500

Policy Coverage Limit Premium Endorsements Limit Premium

Personal Property (Coverage B) 20,000 204.00
Personal Liability (Coverage L) each 100,000 Back-Up Sewer/Drain - Contents 15% 3,000 2.00
occurrence Only, 15% of Personal Property
Medical Payments (Coverage M) each 1,000 Fungus (Including Mold) Limited 10,000
occurrence Coverage included
Credit Card / Bank Card and Forgery 1,000
Damage to Property of Others (Each 1,000
Occurrence)
Loss of Use 8,000
Loss Settlement Options
Loss Settlement Option - Personal B1 - Limited 35.00
Property Replacement
Cost
Accepted Options Declined Options / Endorsements
Jewelry and Furs 1,000 included Addl Insured - Special Event
Silver / Goldware Theft - Option SG 2,500 included Back-Up Sewer/Drain - Contents
Only, 30% of Personal Property
Business Property - Option BP 1,500 included Business Property - Option BP 2,500
Firearms - Option FA 2,500 included Business Property - Option BP 5,000
Business Pursuits - Option BU
Cyber Event, Identity Restoration, and
Fraud Loss Coverage
Earthquake Endorsement
Firearms - Option FA 5,000
Fungus (Including Mold) Limited 25,000
Coverage
Home Rental
Incidental Business - Option IO
Jewelry and Furs 1,500 / 2,500
Option JF
Jewelry and Furs 2,500 / 5,000
Option JF
Nurses' Professional Liability
Off Premises Structures
Personal Injury
Rented Personal Property
Silver / Goldware Theft - Option SG 5,000
Silver / Goldware Theft - Option SG 7,500
Silver / Goldware Theft - Option SG 10,000
Waterbed Liability
Windstorm or Hail Exclusion

Discounts / Charges
Claim Record (30.00)
Home alert (3.00)
Home / Auto discount (35.00)
Policy deductible (16.00)

EB 2615 GA.6 Rev. 10-2020 Page 1 of 2

 State Farm Fire and Casualty Company Applicant Name: CHACON, JORDAN
Binder Effective Date: 12-10-2021
GA Renters
Application / Binder-Receipt 11-G1-S778-0

Total Premium: $157.00

Amount Paid: $0.00
Credit Amount:
Balance Due: $0.00

UNDERWRITING:
Has applicant had any losses, insured or not, in the past 5 years: No

APPLICANT(S) ACKNOWLEDGEMENT:
By submission of this application, you agree that: (1) You have read this application, (2) your statements on this application are correct, (3) the coverages,
including options and endorsements, and the amounts of coverage on this application are those chosen by you, and (4) the premium charged must
comply with State Farm's rules and rates and may be revised.

BINDER:
State Farm will provide coverage to the applicant and his or her legal representative on the property described for up to ninety (90) days from the Effective
Date, subject to all terms and conditions of the policy and endorsements for which application has been made. If no Effective Date is indicated, this Binder
does not provide any coverage. This Binder will be void when the declarations page is issued on the policy for which application has been made or when
coverage under this Binder is canceled in accordance with policy provisions.

The premium due State Farm for the coverage provided by this Binder will be the full annual premium for the policy for which application has been made, and
will be pro-rated for the length of time coverage is provided under this Binder.

AGENT INFORMATION:
App date and time: 12-03-2021, 11:43 AM
Agent: Leslie Brooks Agent / AFO Code: 2279 / 27FA26 Agent Phone: (678)218-0777
Location Address: 1670 McKendree Ch Rd Ste 1100
Lawrenceville, GA 30043-6677

IMPORTANT NOTICES

REGARDING CONSUMER REPORTS...

Consumer reports, including credit and insurance loss history reports, may be ordered in conjunction with this application to help determine your eligibility
for insurance and the price you are charged. In addition, consumer reports may be used to determine the price you are charged at renewal. We may also
obtain and use a credit-based insurance score developed from information contained in these reports. We may use a third party in connection with the
development of your insurance score. A brochure explaining how State Farm uses consumer reports is available upon your request. For additional
information, please contact your State Farm agent.

REGARDING YOUR COVERAGE AMOUNT...

The State Farm replacement cost is an estimated replacement cost based on general information about your residence. It is developed from models
assuming a variety of contents in a typical unit. The actual cost to replace your personal property may be significantly different. State Farm does not
guarantee that this figure will represent the actual cost to replace your personal property. You are responsible for selecting the appropriate amount of
coverage. Higher coverage amounts may be selected and will result in higher premiums.

REGARDING CLAIM RECORD RATING PLAN AND LOYAL CUSTOMER DISCOUNT PLAN
With our Claim Record Rating Plan and Loyal Customer Discount Plan, your savings will typically increase the fewer claims you have and the longer you're
insured with State Farm. We adjust premiums based on the number of claims under the rating plan. Depending on your state, claims under the plan
generally include those resulting in a paid loss and may include weather-related claims where permitted. In addition, any claims with your prior insurer
resulting in property damage or injury may also influence your premium.

Our Loyal Customer Discount provides a premium discount based on the number of years that you have been with us.

For more information about whether the Claim Record Rating Plan applies in your state, the claims we consider for the plan, or whether the Loyal
Customer Discount Plan is in effect in your state, please contact your State Farm agent.

REGARDING PERSONAL, FAMILY OR HOUSEHOLD INSURANCE TRANSACTIONS...

We may collect personal information from persons other than the individual or individuals applying for coverage. Such personal information as well as other
personal or privileged information subsequently collected may, in certain circumstances, be disclosed to third parties without your authorization as
permitted by law. If you would like additional information about the collection and disclosure of personal information, please contact your State Farm agent.
You may also act upon your right to see and correct any personal information in your State Farm files by writing your State Farm agent to request this
access.

EB 2615 GA.6 Rev. 10-2020 Page 2 of 2