Habitational Form HiddenAgentsPlease SelectMichelle CortesAllie CoxWally CoxSarah GrantLogan RobertsDarren SteadmanCorporate Name DBA Name Location/Physical Address Street Address City State / Province / Region ZIP / Postal Code Contact Person First Last PhoneEmail Federal Identification Number Mailing Address If Different Than Address Above Street Address City State / Province / Region ZIP / Postal Code In what year was the business established? How many years of management experience in this industry does the applicant have? How many Property Additional Interests (Mortgagees/Loss Payees/Additional Insured) are required? The insured has maintained continuous coverage for the business Yes No Type of Quote Requested: Apartments Condominiums/Townhomes Dwelling 1-4 Units HOA/Planned Unit Development Property Includes: Smoke alarms are installed in all units and hallways. Balcony and/or stairwell rail spacing is less than 4 inches and railing height is taller than 42" inches. Interior stairwells are present, but NOT equipped with automatic closing fire doors on each floor. Woodburning stoves, kerosene and/or coal burning heating devices are present in units or common areas. Security bars on windows are present WITHOUT quick release. Ponds, private lakes, streams, or beaches owned or maintained by the applicant. Known allegation(s) of sexual abuse or molestation against an owner, manager, or employee. Total Part Time Employees for All Locations Total Full Time Employees for All Locations What is the total annual Rents from this location? Year Built Construction Type:Frame/Stucco/Brick VeneerMasonryMasonry Non-CombustibleModified Fire ResistiveFire ResistiveRoof TypeShakeTileComposition ShingleFlat-RubberFlat-ThermoplasticBuilt-up BitumenBuilt-up Modified BitumenBuilt-up Tar/GravelOtherNumber of Buildings:Number of Units or Apartments:Number of Stories:Ground Floor Area Square Footage for All Buildings:Fire Sprinkler System: Yes No Is the sprinkler system regularly maintained? Yes No Contractor Name / Inspection Company If it fully or partially sprinklered? Yes No Property Includes: Detached Carport Detached Garage Elevator Guard House Mail Boxes Solar Panels Tennis Courts Building Improvements/Renovations at this location:Has the building undergone a comprehensive renovation since it was originally built? Yes No Wiring Year if Replaced Entirely: Not upgraded, entire system replaced down to studsPlumbing Year if Replaced Entirely: Not upgraded, entire system replaced down to studsRoofing Year: Heating Year: Read each question carefully and check all that apply:Property Includes: Exterior doors are equipped with deadbolt locks with a change lock procedure in place Residents are permitted to use charcoal barbeques on wood decks, balconies or patios The original building(s) was converted from a different occupancy or operation (e.g. hotel to apartment, or 1 unit to 4, etc.) Armed guards contracted to patrol the premises There is pre-existing damage or water damage to the building Indicate type of alarm at this location: None Central Station Local UL with Certificate This location offers housing under HUD Section 8 or Section 202 Program Yes No Are there any pools, spas, or hot tubs on the Premise? Yes No How Many Pools:How Many spas or hot tubs:Pools/Spa/Hot Tubs Conditions: There are diving boards or slides in the pools Depths are clearly marked, safety rules are posted, and a life saving apparatus is available All pools and spas have a 5-foot non-climbable fence and self-locking gate All pools/spas are equipped with an anti-entrapment device and/or system for a drain cover in compliance with the Pool Safety Act If a playground is present, does the surface consist of sand/bark/wood/pea gravel or synthetic rubber? Yes No N/A Is the property located next to a marina, dock or lakefront? Yes No Is any portion of the risk a time share or short term rental property? Yes No Are there any other occupants of this building that are not Habitational? Yes No Enter any exposures the insured owns or is responsible for maintaining:Number of Athletic Courts (e.g. tennis, basketball, handball, etc):Number of Playgrounds:Number of Ponds/Lakes:Miles of Community Roads:Acres of Greenbelt:Miles of Open Space Trails:Are there any past or pending/ongoing Cyber related claims? Yes No Are there any known situations, past or pending, that could give rise to a claim? Yes No For HOA's & PUD’s OnlyPercent of Units Rented What is the total annual Association's fees for the HOA? For Condo HOA’s: Do you cover this inside of the units - called "Unit Owners Coverage" or only have a “studs out/ bare walls" policy? Yes No Select one of these: Unit Owners Coverage “Studs Out”/Bare Walls Current Umbrella Limit:Please Select$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$10,000,000$15,000,000$20,000,000$25,000,000$30,000,000Current Directors & Officers Coverage Amount:Please Select$500,000$1,000,000$2,000,000Aggregate Limit$500,000$1,000,000$2,000,000Self Insured Retention$500$1000$2500$5000$10000Number of Directors:Current Fidelity/Employee Dishonesty Coverage Amount:Number of Employees:Reserve Funds:Has the Association ever had a lapse in coverage for directors and officers liability? Yes No Do you have full prior acts' coverage? Yes No Has the Organization ever been declined, cancelled, rescinded or non-renewed for Directors and Officers, or Discrimination/Employment Practices liability coverages? Yes No Any special assessments either pending or demanded in the past 24 months? Yes No During the last five (5) years, have any claims, demands, complaints, grievances or potential claims (including Discrimination and Employment Practices) been made orally or in writing, or any lawsuits, charges or legal proceedings been filed against the entity, or any person in their capacity as a past or present director, officer, employee or volunteer of the entity? Yes No Are there any known facts, circumstances or situations, past or pending / ongoing, that could give rise to a claim including without limitation, any actual, threatened or suspected claims, demands, complaints, grievances or charges, including any employment practices or discrimination, made against the entity, it’s directors, officers, employees or volunteers? Required Yes No To expedite your Proposal, we need the following for all risks:Loss History for the Past Five YearsWe need this to provide discounts, and for Underwriting approval. Claims History – aka “loss runs” are ordered by you from your current Agent and/or Insurance Company. It is a good business practice to order these yearly. Loss History is only provided to Owner / Property Manager, we do not have access or authority to requestMax. file size: 128 MB.Fire Sprinkler Inspection Report Drop files here or Select files Max. file size: 128 MB. To obtain and verify eligibility for having a fully fire-sprinkler system, please upload the most recent Fire Sprinkler Inspection report(s).CC&R’s for AssociationsWe can review and confirm the Insurance requirements of the Association.Max. file size: 128 MB.Copies of your PropertyLiability and Umbrella Coverages, if any.Max. file size: 128 MB.CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
