The X. Y. Company of ---------, herein called the company, in consideration of --------- dollars premium, and of the statements contained in the Schedule attached hereto and hereby made a part hereof, which statements the Assured makes on the acceptance of this Policy and warrants to be true, does hereby agree to indemnify A. B., of ---------, County of ---------, State of ---------, herein called the Assured, in the total sum of ------- dollars ($---------), and no more, for the term of ---------months, beginning on the ---------day of ---------, 19-., at noon, and ending on the --------- day of ---------, 19-, at noon, Standard time, subject to the following Special and General Agreements which are to be construed as co-ordinate as conditions and precedent to any recovery hereunder.

Residence Theft Rider - Schedule

1. Name of Assured ---------

2. Location of the building --------- [street and number]; --------- [city or town]; --------- [state].

3. There is a regular day and night police force in the city or town of ---------men.

4. The building is fully described as follows --------- [state whether private residence, boarding house, non-housekeeping apartment house or flat house.]

5. The part of the building occupied by the Assured and defined herein as the premises is --------- [state whether entire house or appartment or flat, and on which floor].

6. If an apartment or flat house, there is a regular front door, hall or elevator attendant, except as follows: -------.

7. The premises as defined in this Policy are not used in whole or in part as a boarding house or lodging house, nor by any physician, surgeon, oculist or dentist for the reception or treatment of patients except as follows: ---------.

8. The business address of the Assured is---------.

9. The occupation of the Assured is ---------.

10. The Assured has no burglary, theft or larceny insurance, has never been refused any and has applied for none except as follows: ---------.

11. The Assured has not sustained any loss nor received indemnity for any loss by burglary, theft or larceny except as follows: ---------.

12. The insurance granted by this Policy attaches specifically as stated below in Items a, b and c and subject to such limits, the total amount of insurance and the total liability of the Company hereunder is limited to $------.

a $---------On Money (subject to the limits as specified in special agreement

B 2). Watches, Jewelry, Precious Stones, Sterling Silver, Wearing Apparel, Furs, Laces, Plated Ware, Rugs, Tapestries, Curtains, Shades. Beds, Bedding, Linen, Engravings, Etchings, Paintings, Fixtures, Books, Bronzes, Statuary, Clocks, Bric-a-Brac, Articles de Vertu, China, Crockery, Glassware, Lamps, Cameras, Sporting Outfit, Musical and Professional Instruments, Furniture, Mirrors. Carpets, Fixtures for Plumbing, Gas, Water and Electricity and other Personal Effects common in residences generally, but excluding Fuel, Wines, Liquors and Family Stores, and also excluding articles mentioned in Items b and c.

Premium $ ------b $---------On articles in the said premises, specifically insured as follows:

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

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

Premium $ ------ c $---------On ..........

Premium $ Total Premium $---------

Attached to and forms part of policy No. B--------- of the X. Y. Company of ---------. ---------, Agent.

For direct loss by burglary, theft or larceny of any of the property of the Assured, described in the said schedule and stated therein to be insured hereunder, occasioned by its felonious abstraction from the interior of the house, building, apartment or rooms actually occupied by the Assured, also described in the said schedule, and hereinafter called the premises, by any domestic servant or other employe of the Assured or by any other person or persons excepting any person whose property is insured hereunder; and for direct loss by damage to the said property and to the said premises caused by burglars or thieves.

Special Agreements

A. (1) It is understood and agreed that for the purpose of this insurance, property belonging to any permanent member of the household of the Assured who does not pay board or rent, excepting domestic servants or other employes, or property belonging to a relative of the Assured permanently residing with him, is deemed to be the property of the Assured. In the event of claim for loss of such property, the release of either the Assured or the actual owner of the property shall relieve the Company from all further liability. (2) Premises within the meaning of this Policy is limited as follows:- If the Assured occupies the entire building designated in the schedule, the term is limited to the interior of the said building excluding porches and areaways; if the Assured occupies only a part of the said building, the term is limited to the Interior of the room or rooms actually occupied by the Assured on the floor designated in the schedule and excludes entrances, halls and stairways. (3) The premises shall be deemed to be unoccupied when neither the Assured nor a member of his household is actually in the premises.

B. The Company shall not be liable for any loss:- (1) If the premises are left without an occupant for more than four months unless written permission for a further period of non-occupancy is endorsed hereon or attached hereto; but in no event shall the liability of the Company hereunder exceed One Hundred Dollars ($100.00) for loss of jewelry, precious stones or watches, occurring in the premises during any period of non-occupancy exceeding eighty-four (84) consecutive hours whether such loss occurs within the period of eighty-four (84) consecutive hours or not. (2) Of money in excess of five per cent. of the amount of insurance granted under Item a of Statement 12 of the schedule but in no event in excess of Fifty Dollars ($50.00). (3) Of coin and stamp collections unless the same are specifically insured under Item b of Statement 12 of the schedule. (4) Of securities for money. (5) Unless the Assured shall produce direct and affirmative evidence that the loss of the articles for which claim is made was due to the commission of a burglary, theft or larceny; the disappearance of said articles not to be deemed such evidence.

C. While the premises are unoccupied within the meaning of this policy, and mechanics or other work people are admitted into the premises for the purpose of painting, papering, renovating or making any alterations or changes of any nature in the premises, the Company shall not be liable under this policy for any loss unless such loss is occasioned by a person or persons who have made felonious entry into the premises by force and violence, of which there shall be visible marks made by tools or explosives, upon the premises.

D. If the Assured is the occupant of an apartment or flat house, this insurance covers in amount of five per cent, of the amount of insurance granted under Item a of Statement 12 of the schedule, hut in no event in excess of Fifty Dollars ($50.00), in a locked storeroom in the same house provided by the landlord and used exclusively by the Assured.