9200 E. Pima Center Parkway, Ste 350 • Scottsdale, AZ85258
1-800-873-9442 • Fax (480) 596-7859

Apartment Liability Supplemental Application

(To be completed in addition to the ACORD Application)

Applicant’s Name:

DESCRIPTION OF LOCATIONS

Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
Years owned
Type ofoccupancy*
Year built
Number of Stories
Number of Units—total
Number of
Buildings
Total square feet
Pool?—see
section C. / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
Manager on
premises? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
If occupancy is mixed, please
describe the non-habitational
occupancy.
Square feet
Percent of units subsidized / % / % / % / % / % / %
Percent of university or college students as tenants / % / % / % / % / % / %

*Use alpha code listed for type of occupancy:

A—Apartment BuildingB—Garden apartmentsC—Apartment hotel/timeshare
DESCRIPTION OF LOCATIONS (continued)

Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
If student housing, is this strictly graduate or family housing? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
Minimum lease term?
How many times have the authorities been called?
Subcontracted work—Anticipated cost nexttwelve (12) months / $ / $ / $ / $ / $ / $
Certificates for subcontractors on file? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No

*Use alpha code listed for type of occupancy:

A—Apartment BuildingB—Garden apartmentsC—Apartment hotel/timeshare

1.Are any of the properties residential senior, or retirement centers or assisted living centers?...... Yes No

a.If yes, what is the percentage of non-ambulatory above the fifth (5th) floor?...... %

b.If yes, do units have a pull chord or emergency notification systems?...... Yes No

c.If yes, do you have posted emergency evacuation plans?...... Yes No

2.Are any of the properties housing authorities or do they include subsidized housing?...... Yes No

If yes, explain:

3.Are any locations currently or planned to be under renovation?...... Yes No

a.If yes, please describe the renovation:

b.Do renovations include conversions to condominiums or townhouses?...... Yes No

RENOVATION/MOST RECENT UPDATE*

Year and Type of Update / Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
Sidewalks and parking
Patio balconies, railings, and stairways

* Update information for electrical, plumbing, heating and roofing must be completed on the Acord.

SWIMMING POOL(S)

Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
Number of pools
Pool depth
Diving board / platform height
Slide height

SWIMMING POOL(S) (continued)

Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
Fully fenced with self latching gate? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No
Compliance with Virginia Graeme-Baker pool and spa safety act? / Yes No / Yes No / Yes No / Yes No / Yes No / Yes No

1.Are the depth markings clearly shown?...... Yes No

2.Are warning signs and rules posted and clearly visible?...... Yes No

3.Is rescue equipment, including a ring buoy and twelve (12) foot pole or shepherd's hook, available poolside?... Yes No

4.Is pool maintained by applicant or outside contractor?...... Applicant Outside Contractor

If outside contractor, are certificates of insurance on file?...... Yes No

5.Are lifeguards provided by:...... Applicant Pool Management Company

If provided by pool management company are certificates of insurance on file?...... Yes No

MAINTENANCE

1.Are sidewalks salted for snow or ice conditions?...... Yes No Not applicable

2How quickly is snow removed?

3.Who is responsible for upkeep of sidewalks and driveways?

If subcontracted, are subcontractor certificates kept on file with AI status and limits equal to or greater than those proposed? Yes No

FIRE PROTECTION

1.Sprinklered?...... Yes No

All units?...... Yes No

Common areas only?...... Yes No

2.Smoke detectors in each unit?...... Yes No

If yes: Hard-wire or battery? How often checked?

3.Carbon Monoxide detectors in each unit?...... Yes No

If yes: Hard-wire or battery? How often checked?

4.Fire extinguishers?...... Yes No

In common areas?...... Yes No

In each unit?...... Yes No

SECURITY

1.Is security provided?...... Yes No

If yes, what type? Patrol Gated access Alarm systems in each unit Security cameras

2.If patrol, please answer the following questions:

a.Armed or unarmed?

b.Are the guards employees of the management or independent contractors?...... Management Independent contractors

If independent contractors, are certificates of insurance required?...... Yes No

Is the applicant named as additional insured on their policy?...... Yes No

c.Is the security twenty four (24) hours? ...... Yes No

3.Do the residents' doors or windows contain any of the following?

Viewing windows in front doorsLock pins for windows and sliding glass doors

Window locks/barsDead bolts

4.Do any windows have burglar bars?...... Yes No

If yes, do the burglar bars have interior emergency quick releases?...... Yes No

If no, please list locations that do not have the emergency release:

OTHER RECREATIONAL EXPOSURES

Number of: / Loc. No. 1 / Loc. No. 2 / Loc. No. 3 / Loc. No. 4 / Loc. No. 5 / Loc. No. 6
Baseball field(s)
Basketball court(s)
Beaches
Bike trails (miles)
Boat slip(s)
Clubhouse (sq. ft.)
Lakes/Ponds (acres)
Parks (acres)
Playground(s)
Racquetball court(s)
Saunas
ShootingRanges
Spa/Hot tub(s)
Stables
Streets/Roads (miles)
Tennis court(s)
Volleyball court(s)

1.Other:

2.Are these available to nonresidents for a fee?...... Yes No

If yes, annual receipts:...... $

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)

PRODUCER’S NAME:

AGENT’S NAME:LICENSED NO.:
(Applicable to Florida’s Agent’s Only)

NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE

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