THE PROVIDENCE MUTUAL FIRE INSURANCE COMPANY

P.O. Box 6066

Providence, RI 02940
(877) 763-1800 | providencemutual.com
August 23, 2021
LINE OF BUSINESS POLICY NUMBER
HOMEOWNERS HP 0681655 03
AGENCY
ROBERT WILKENS INS. AGENCY
52 WEST MAIN STREET
BOGOTA, NJ 07603

201-343-1741
INSURED
SHAH, KHUSHBOO
SHAH, HIRAL
20 MACIOROWSKI RD
PARLIN NJ 08859-1689
Thank you for renewing your policy with Providence Mutual. We appreciate your trust in us
to protect your valuable assets. We continue to honor our promises and to be here for you
today, tomorrow and the day after.

You will find your most current renewal policy enclosed in this packet. If you have any
questions after reviewing these materials, please contact your agent listed above.

If you experience a claim we will provide you with the security of a prompt response from
our claims department. Please contact your agent, report the claim on our Policyholder
Portal or call us at 1-877-763-1800.

To learn more about Providence Mutual, visit our website at providencemutual.com. Also,
our Policyholder Portal allows you to pay your bill, report a claim and obtain information
about your policy online. To register, visit mypmfic.com/policyholder and use your email
address and personal activation code 10699373 to register your account.

Thank you for choosing Providence Mutual.

Sincerely,

Michele Streton
President and CEO
 HOMEOWNERS POLICY NUMBER
POLICY HP 0681655 03
DECLARATIONS THE PROVIDENCE MUTUAL FIRE INSURANCE COMPANY
BOX 6066, PROVIDENCE, RI 02940 REASON FOR COVERAGE SELECTION
RENEWAL
Effective Date: 10/05/2021

NAMED INSURED AND ADDRESS AGENT

SHAH, KHUSHBOO ROBERT WILKENS INS. AGENCY 1611
SHAH, HIRAL 52 WEST MAIN STREET
BOGOTA, NJ 07603
20 MACIOROWSKI RD
PARLIN NJ 08859-1689 201-343-1741
The described residence premises covered hereunder is located at the
above address, unless otherwise stated herein. (No., Street, City, State, Zip Code)
PREVIOUS POLICY NUMBER HP 0681655
20 MACIOROWSKI RD Direct Bill Full Payment
PARLIN NJ 08859-1689 THIS IS NOT A BILL - SEE
YOUR BILLING STATEMENT
Policy Period: Annual From 10/05/2021 To 10/05/2022 12:01 AM STANDARD TIME

COVERAGE AND LIMITS OF LIABILITY

Coverage is provided where a premium or limit of liability is shown for the coverage:

SECTION I SECTION II
A. DWELLING B. OTHER C. PERSONAL D. LOSS E. PERSONAL F. MEDICAL PAY
STRUCTURES PROPERTY OF USE LIABILITY EACH PERSON
$ 893,000 $ 89,300 $ 446,500 $ 267,900 1,000,000 $ 5,000

DEDUCTIBLE
FOR LOSSES ARISING UNDER SECTION I, WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $ 1,000
PREMIUMS
TOTAL ADDITIONAL/RETURN
PREMIUM PREMIUM
$1,694.00
New Jersey Property-Liability Insurance Guaranty Association Surcharge $ 10.00
OPTIONAL PREMIUMS
DESCRIPTION LIMIT PREMIUM

Personal Liability 1,000,000 $ 47.00

Medical Pay Each Person 5,000 $ 11.00
Age of Home Credit $ 150.00CR
Deductible Credit $ 190.00CR
Equipment Breakdown 100,000 $ 50.00
Identity Theft $ 14.00
Inflation Guard Included
Limited Fungi Coverage Included
PP Replace Cost $ 231.00

OPTIONAL PREMIUM $183.00CR

ENDORSEMENTS
FORMS and ENDORSEMENTS made part of this Policy at time of issue:
FORM ED. FORM ED.
NAME DATE FORM DESCRIPTION NAME DATE FORM DESCRIPTION
HO2492 (04/02) Workers Comp HO0003 (05/11) Special Form
HO0129 (05/11) Special Provisions - NJ INFLOOD (03/03) New Jersey Flood Notice
PMFICHO1 (04/02) Amendatory Endt-Sect I Cov B NJAS (01/10) Notice Policyholders NJ Surch.
NJNTSR (01/09) Third Party Notification NPCR0001 (02/15) Use of Credit Based Ins Scores
PMHO53 (06/12) Escaped Fuel Prop Rem - NJ PMHO55 (06/12) Lead Liability Exclusion - NJ
PMHO56 (06/12) Asbestos,Radon & Comm Dis Excl EQNJ01 (04/17) NJ EQ Insurance Availability

Issued Date: 08/23/2021 Countersigned Date

PMFOP THIS DECLARATIONS PAGE, SUPERSEDES ANY PREVIOUS DECLARATIONS AND WITH POLICY, FORMS AND ENDORSEMENTS, IF ANY, Page 1 of 2
ISSUED TO FORM A PART THEREOF COMPLETES THE ABOVE NUMBERED HOMEOWNERS POLICY.
HODEC
INSURED
MUTUALS - MEMBERSHIP AND VOTING NOTICE: The insured is notified that by virtue of this policy, he is a
member of The Providence Mutual Fire Insurance Company, and is entitled to vote either in person or by proxy at
any and all meetings of said Company. The Annual Meetings are held on the fourth Tuesday of February, in each
year, at 11:30 o'clock A.M.
MUTUALS - PARTICIPATION CLAUSE WITHOUT CONTINGENT LIABILITY: No Contingent Liability: This policy is
nonassessable. The policyholder is a member of the company and shall participate, to the extent and upon the
conditions fixed and determined by the Board of Directors in accordance with the provisions of law, in the
distribution of dividends so fixed and determined.

In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this
policy shall not be valid unless countersigned by our authorized representative.

Thomas F. Burkart, Secretary Michele Streton, President

 HOMEOWNERS POLICY NUMBER
POLICY
HP 0681655 03
DECLARATIONS THE PROVIDENCE MUTUAL FIRE INSURANCE COMPANY
BOX 6066, PROVIDENCE, RI 02940 REASON FOR COVERAGE SELECTION
RENEWAL
Effective Date: 10/05/2021

NAMED INSURED AND ADDRESS AGENT

SHAH, KHUSHBOO ROBERT WILKENS INS. AGENCY 1611
SHAH, HIRAL 52 WEST MAIN STREET
BOGOTA, NJ 07603
20 MACIOROWSKI RD
PARLIN NJ 08859-1689 201-343-1741
The described residence premises covered hereunder is located at the PREVIOUS POLICY NUMBER HP 0681655
above address, unless otherwise stated herein. (No., Street, City, State, Zip Code)

20 MACIOROWSKI RD Direct Bill Full Payment

PARLIN NJ 08859-1689 THIS IS NOT A BILL - SEE
YOUR BILLING STATEMENT
Policy Period: Annual From 10/05/2021 To 10/05/2022 12:01 AM STANDARD TIME

OPTIONAL PREMIUMS
DESCRIPTION LIMIT PREMIUM
Protective Device Credit $ 212.00CR
Renewal Credit $ 179.00CR
Replacement Cost Bldg $ 47.00
Service Line Coverage 10,000 $ 20.00
Water Backup and Sump Overflow $ 117.00
Work Comp Coverage $ 1.00

ENDORSEMENTS
FORMS and ENDORSEMENTS made part of this Policy at time of issue:
FORM ED. FORM ED.
NAME DATE FORM DESCRIPTION NAME DATE FORM DESCRIPTION
NJHOSUMM (05/15) Summary of Homeowners Coverage HO0648 (10/15) Residence Prem. Def. End.
HOP004 (05/11) HO Daycare Advisory Notice ADIL01 (01/21) Electronic Delivery
PMHO60 (12/13) Equipment Breakdown Enhance HO0416 (10/00) Premises Alarm or Fire Prot Sy
PMHO29 (10/09) Inflation Guard HO0490 (05/11) Pers Prop Replacement Cost End
HO0420 (05/11) Specified Add'l Amt Insurance HO0427 (05/11) Limited Fungi (HO 3 & 5)
PMHO67 (12/13) Service Line Coverage HO0455 (05/11) Identity Theft Exp.
HO0653 (02/17) Home Sharing Amend HO3 HO0495 (05/11) Water Back Up and Sump Overflo

MORTGAGEES
JP MORGAN CHASE BANK NA
ISAOA ATIMA
PO BOX 4465
SPRINGFIELD OH 45501-4465
LOAN # 1857932854

RATING INFORMATION
Protection Statement
Families Territory Protection Not more than indicated ft. Not more than indicated Occupancy Construction Renovation
Class from Hydrant or Fire Well miles from Fire Dept. Type Type Year Year
1 4403 05 1000 5 P F 2005

Issued Date: 08/23/2021

PMFOP THIS DECLARATIONS PAGE, SUPERSEDES ANY PREVIOUS DECLARATIONS AND WITH POLICY, FORMS AND ENDORSEMENTS, IF ANY, Page 2 of 2
ISSUED TO FORM A PART THEREOF COMPLETES THE ABOVE NUMBERED HOMEOWNERS POLICY.
HODEC
INSURED