Notice of Insurance Information Practice

Personal information about you may be collected from persons other than you. Such information as well as other personal and privileged information collected by Ellis Insurance, Wine Services Alliance, American International Group, and/or QBE Americas may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our file and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact Ellis Insurance for instructions on how to submit such a request.

This census does not bind the applicant or the Company, but is agreed that this form shall be the basis of the contract of a policy to be issued, and it will be attached to and made a part of the policy. The applicant represents that if the information supplied on this census changes between the date of this census and the time when the policy is issued, the applicant will immediately notify the Company of such changes.

I declare the answers in this census are, to the best of my knowledge and belief, true and complete and I agree that:

The insurance on scheduled wines shall become effective after all the following conditions have been met:

· The full amount of the annual premium has been paid; and

· The Company has approved the application according to its established limits, rules and standards.

The Company is not bound by any statements made by or to any agent unless such statements are written in the application and accepted by the Company.

The acceptance of the policy, containing a copy of the application, by me is acknowledgment and ratification of any modifications made in the application, and that no change in the current values and limit of liability specified on the inventory schedule(s) and the total limit of liability in the aggregate over all locations will be made unless agreed to in writing by the Company.

Advice to New York applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.