Policy Information:
Policy Number -
Insured Name 1  
Insured Name 2  
Address 1
Address 2
City         State Zip
Telephone Number - -

Producer:
NYPIUA Producer Number -
Name 1  
Name 2  
Address 1
Address 2
City         State Zip
Telephone Number - -

Location of Property:
Location #
Address 1
Address 2
City         State Zip

Requested Effective Date / /

TYPE OF COVERAGE

Building
Household Furnishings
Additional Living Expense
Improvements, Alterations & Additions

ENDORSEMENT

Increase Existing Coverage Amount
          Current Amount of Insurance
          Increase by
          New Amount of Insurance

Add New Cause(s) of Loss
        Add Extended Coverage only
        Add Extended Coverage and Vandalism & Malicious Mischief

Add New Coverage
          Amount of Insurance desired
          Risk Description