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NORTH CAROLINA INSURANCE UNDERWRITING ASSOCIATION

CERTIFICATE OF ESSENTIAL PROPERTY INSURANCE

(Applicable to Beach and Coastal Areas)

A COPY OF THE ESSENTIAL PROPERTY DECLARATIONS, AN ACORD CERTIFICATE OF INSURANCE

OR THIS CERTIFICATE MUST BE SUBMITTED TO APPLY FOR WINDSTORM & HAIL INSURANCE

The North Carolina Insurance Underwriting Association cannot, by law, provide Windstorm & Hail insurance unless it is provided a

certificate, properly completed and signed, that Essential Property Insurance {as defined by G.S. 58-45-35(e)}, written by a licensed

insurer, is in force. “Essential Property Insurance ", as defined by G.S. 58-45-5(4), means insurance against direct loss to property as

defined in the standard statutory fire policy and extended coverage, vandalism and malicious mischief endorsements thereon, as

approved by the Commissioner."

If the Essential Property Insurance policy listed below is terminated or cancelled and you are unable to replace the coverage through a

licensed insurer, you may be eligible for Essential Property Insurance through the North Carolina Joint Underwriting Association

(FAIR Plan) or the North Carolina Insurance Underwriting Association (Beach Plan). You should contact your Agent or the

Associations for details.

Owner of Property to be Insured: __________________________________________________________________

Location of Property to be Insured: ________________________________________________________________

_____________________________________________________________________________________________

Name of Insurance Company providing Essential Property Insurance: (If the Essential Property Carrier required completion

of a Form F Application, Windstorm and Hail coverage is not available through the NCIUA.)

_____________________________________________________________________________________________

Company Underwriting Office: ___________________________________________________________________

Telephone Number: (____)___________________ Name of Underwriter: ________________________________

Policy Number: _____________________Inception Date: _____/_____/_____ Expiration Date: _____/_____/_____

(The Windstorm & Hail Policy and the Wrap Around Policy must be as concurrent as possible. Exception: The Association reserves

the right to require a different deductible than the Essential Property Carrier. A Short Term Policy will be written to satisfy the date

concurrency requirement.)

Amount of Essential Property Insurance in Force: Building: $__________________ Personal Property: $________________

Essential Property Policy’s Deductible $______________Commercial Only-Business Income: $ _________________

Residential Wind Driven Rain Coverage Desired? ____Yes ____No (check one) This coverage is not available in Commercial

Property. Residential Wind Driven Rain Coverage is only available if the essential carrier’s policy would not have excluded Wind

Driven Rain, and is applicable to building coverage only. A copy of the essential carrier’s policy is needed for proof of coverage if

that policy is other than HE-7, HO-3 or DP-3.

If Essential Property Policy is written on Commercial Form, show Fire Class Rate CSP Code: ________________

Essential Policy's Applicable Basic Policy Form(s): _________________________________________________

Replacement Cost Provided (check one) ___Yes ___No Building; ___Yes ___No Personal Property

(Note: Replacement Cost on Personal Property is not available over a Dwelling Fire Policy)

Dwelling is (check one): _____ Primary Location _____ Secondary Location

Does this Essential Property Insurance Policy include "Write Your Own" flood coverage? (check one) ____ Yes ____ No

********************************************

I certify that the policy referenced above is in force at this time.

Signature: _____________________________________________ Date: ___________________________

WH0005 09 07

Form Wh0005 - Certificate Of Essential Property Insurance - North Carolina Insurance Underwriting Association