SECTION I: Eligibility
Buildings / exposures / amenities / claims history:
The following buildings/exposures/ amenities / claims historyare either not eligibleor eligible with restrictions:
- Not Eligible:
- Condominiums / apartments / timeshares
- Clubhouses older than 20 years that have not had the roof, HVAC, plumbing and
- Clubhouses with aluminum wiring unless repaired through “pig-tailing”, CO/ALR
- Clubhouses without smoke detectors
- Aircraft (hired, leased, or owned), airports, or landing strips
- Day care (if owned and /or managed by the insured)
- Golf courses (if owned and /or managed by the insured)
- Marinas or dams
- Mobile home / trailer / RV parks
- Retirement communities with assisted living / nursing facilities
- Riding amenities or public trails
- Armed security, arrest authority or usage of self-protection tools such as mace, nightsticks, handcuffs, etc.
- Passenger transportation services whether provided by the insured or contracted out to a third party
- Short-term or seasonal rental of units
- Skateboard parks or ice skating rinks
- Ski trails, slopes or lifts
- Sponsored athletic events, other than swim teams
- Tanning beds that are owned, operated or maintained by the insured
- Valet services utilizing drivers under the age of 21
- Any commercial building exceeding 150,000 sq. ft.
- Any commercial building owned or managed that are part of the commercial planned unit development
- Any commercial building maintained by the association
- Any maintained or operated shared amenities such as pools, sports courts, health club, etc. by a commercial association
- Risks that allow employees under the age of 21 to drive, whether the insured supplies an owned or hired vehicle or allows employees under the age of 21 to drive their own vehicle to conduct the insured’s business
- We will not write community associations that:
- Rent their common facilities to non unit-owners
- Serve liquor (other than free of charge)
- Risks with the following occupancies:
- Auto / truck dealerships, repair or painting
- Churches / religious institutions
- Family planning facilities, hospital or health care clinics
- Gas stations, storage of radioactive materials, fuels, hazardous flammables or chemicals
- Governmental, municipal or political offices
- Industrial, self-storage or warehousing
- Hotels / motels / resorts
- Restaurants, bars, nightclubs, dance halls, adult entertainmentor any occupancy with a cabaret license
- Retail, strip shopping centers or shopping malls
- Risks with the following kinds of claims or convictions within the last five years or allegations of any such pending actions:
- Violent acts, such as assault, rape or shootings
- Class action lawsuits
- Construction defects lawsuits
- Habitability or tenantability lawsuits
- Eligible with restrictions:
- Pools
- Indoor pools and spas must have card key access and a self-locking door along with surveillance cameras or regular securitychecks
- Outdoor pools and spas must be fenced at least 6’ high and have self-locking gates
- Swimming pool’s design or operation must comply with the Virginia Graeme Baker Act and meet or exceed all federal, state and local governing codes and regulations
- Safety equipment (hooks & float) must be readily available
- We will not write any pool with a diving board, lazy river or slide
- Bodies of water, owned by the insured, such as lakes, ponds, beaches, retention ponds that meet the following guidelines:
- No gasoline or diesel powered boats on the lake
- No ice skating
- No personal watercraft (i.e. wave runners, jet skis, sea doos, etc.) and no water skiing
- No watercraft more than 15 horsepower engines may be permitted
- No watercraft used for transport of passengers
- Lakes & beaches: controlled access and usage: owners and owners’ guests only
- Designated swimming areas
- Proper signage and lighting that meets ANSI standards
- Written policies in place regarding supervision and maintenance program
SECTION II: Broker details
BROKER NAME:
ADDRESS:
CITY: / STATE: / ZIP CODE:
PHONE: / CONTACT NAME:
CONTACT E-MAIL:
SECTION III: Insured information
NAMED INSURED:
MANAGEMENT CO.:(IF APPLICABLE, MUST BE COMPLETED.)
MAILING ADDRESS:
CITY: / STATE: / ZIP CODE:
CONTACTNAME: / PHONE:
PROPERTYADDRESS:
CITY: / STATE: / ZIPCODE:
COUNTY: / FEIN #:
# OF YEARS IN BUSINESS: / # OF YEARS MANAGED BY CURRENT MANAGEMENT CO.:
ASSOCIATION TYPE: HOMEOWNERS ASSOCIATION PLANNED UNIT DEVELOPMENT COMMERCIAL PUD
RESIDENTIAL DESCRIPTION: SINGLE FAMILY TOWNHOUSE MASTER
COMMERCIAL DESCRIPTION: BUSINESS PARK LIGHT INDUSTRIAL OFFICES
SECTION IV: Policy details – Insured
PROPOSED EFFECTIVE DATE: / EXPIRATION DATE:
PRIOR CARRIER INFORMATION:
PACKAGE(Expiring) / CARRIER / EXPIRATION DATE / ANNUAL PREMIUM
$
SECTION V: Location information
- Property coverage
Common building / Sq. ft. / Building value / Contents / # Stories / Year built / % Sprinklered / Alarm system
Clubhouse / Yes No
Construction of building:Walls:Wood frame Brick / block Steel frame
Roof: Wood shake Comp shingle Tile / cement
Floor:Wood frame Poured concrete
Common building / Sq. ft. / Building value / Contents / # Stories / Year built / % Sprinklered / Alarm system
$ / $ / Yes No
Construction of building:Walls:Wood frame Brick / block Steel frame
Roof: Wood shake Comp shingle Tile / cement
Floor:Wood frame Poured concrete
Common building / Sq. ft. / Building value / Contents / # Stories / Year built / % Sprinklered / Alarm system
$ / $ / Yes No
Construction of building:Walls:Wood frame Brick / block Steel frame
Roof: Wood shake Comp shingle Tile / cement
Floor:Wood frame Poured concrete
Other property statement of values
Exposure
/Value
/Exposure
/Value
/Exposure
/Value
Fences – metal or masonry / Fences – wood / Walls - masonrySigns – metal / Signs – other than metal / Kiosks
Pools / Pool furniture / Mailboxes
Spas / Sprinkler system / Trees / shrubs
Streets / Sidewalks / Parking lots
Tennis courts / Basketball courts / Volleyball courts
Monuments / Playgrounds / Entry features
Gates (gated communities) / Lights / poles / Dog park
Cabana (not enclosed)
Total property limits: / $
Property deductible requested:$1,000$2,500$5,000$10,000
Property coverage options (additional cost):
Equipment breakdown coverage requested?: Yes No / Business income limit requested: $
Earthquake sprinkler leakage coverage requested?: Yes NoNote: $25,000 Limit
- General liability coverage
Limit of liability requested:$1 million / $2 million$2 million / $4 million
Residential:# of homes sold: # of homes upon built out: Completion date:
Commercial:# of tenants: # of buildings: Completion date:
Are common buildings leased to outside organizations? / Yes / No
Are subcontractors used? / Yes / No
- Are certificates of insurance obtained?
- Is association named as additional insured?
- Do they carry a minimum GL limit of $1 / 2 million?
Is there a fitness center on premises?
Are subcontractors used? / Yes / No
- Sq. ft. of area:
- Are signed release or waiver of liability forms required?
- Are there fitness trainers?
Childcare / daycare facility on premises? If yes, please complete supplemental application / Yes / No
Are special events conducted (such as parties, concerts, amusement rides, etc)? If yes, attach list of events. / Yes / No
Does insured sponsor any off-premises events? / Yes / No
Riding trails on the premises? / Yes / No
Recreational vehicle storage on the premises? / Yes / No
- Sq. ft. of area:
Commercial:
- Parking lot maintained by:
- Sq. ft. if association maintained:
Common ground – financial responsibility:
Acres of green belt: / Acres of open space: / Miles of maintained trails / streets:
Note: Greenbelt is a landscaped, park-like area that has foot traffic on it. Open space is natural (typically not landscaped) area or streetscapes (grassy medians) or small landscaped areas with no foot traffic.
Playground: N/A
How many? / Type of equipment: / Landing surface:
Sports facilities: N/A
# of tennis courts? / # of basketball courts? / Any other sports or recreational facilities?
Pool / spa: N/A / # of outdoor pools: / # of indoor pools: / # of spas:
Is spa in the same fenced area as the pool? / Yes / No
Swimming lessons? / Yes / No
- Number of participants and range of ages?
Does the association sponsor a swim team? / Yes / No
- Swim team insured separately and association listed as additional insured?
Lakes / ponds / beaches: N/A Please complete supplemental application
How many lakes? / How many ponds? / How many beaches?
- Are any watercraft and / or recreational activities permitted?
Guards: N/A
- Guards employed or contracted?
- If contracted, has the firm been in business for more than 4 years?
- Crime coverage – insuring agreement
Limit
/Deductible
#1 Blanket employee dishonesty: / $ / $#2Forgery or alteration: / $ / $
#3 Inside the premises: / $ / $
#4 Outside the premises: / $ / $
#5 Computerfraud: / $ / $
#6 Money orders & counterfeit paper currency / $ / $
# of officers / directors and employees?
- Is the association crime claims-free for the last 5 years?
- Are dues/fee/mortgage payments always received as checks, not cash?
- Are countersignatures required on all checks over $500?
- Are vouchers/supporting records stamped “paid" when checks are signed? If records arekept electronically, is there a system in place to indicate that a check has been issued toprevent duplication?
- Are persons authorized to hire/fire association employees prohibited from distributing payroll?
If there is no payroll, click N/A.
- Are the association’s bank accounts and credit card statements reconciled monthly by someone not authorized to deposit, withdraw, initiate electronic funds, transfer or use an association’s credit card?
If no, please explain.
- Are persons authorized to hire/fire association employees prohibited from distributing payroll?
If there is no payroll, click N/A.
- Is an audit or review made at least annually by an independent C.P.A.?
- Are mechanically affixed signatures used?
- Does the association have more than 25 employees?
- Other coverages
Inland marine coverage requested? If yes, please complete Acord application. / Yes / No
Hired & Non-owned (NOA) coverage requested? / Yes / No
Note: If NOA coverage is selected and the risk is located in the state of Illinois, the insured must sign the attached Illinois Notice – Uninsured / Underinsured motorists coverage and return it upon binding.
If NOA requested and if employees of the association use their personal auto for HOA related business, do they carry the minimum state liability limits? / Yes / No
No Employees
Owned automobile coverage requested? If yes, please complete Acord application & submit MVRs / Yes / No
Please attach the following documents with package application:
- Carrier generated currently valued loss runs – current year + last three years
- Latest financial statement or budget
- Plot plan of association
SECTION VI: Directors & officers liability(offered outside package through Great American) Quote not requested (skip section)
Expiring carrier: / Limit: / Retention: / Premium:
Requested limit: / Requested retention: / Effective date:
Have there been any D&O claims made against the association in the last 5 years? / Yes / No
Is this the first time the association has purchased D&O insurance? / Yes / No
If no, was association’s prior insurance cancelled or non-renewed by carrier? / Yes / No
If yes to cancellation or non-renewal, explain: N/A
*(N/A option applies to MO applicants only) / Yes / No
Does the association anticipate any major construction or renovations in the next year? / Yes / No
If yes, is it new construction (or continuation of original construction?) Explain:
Is the developer on the board? / Yes / No
If yes, does the developer control the association? / Yes / No
% of units / lots sold: / # of employees:
(0-4 employees are eligible) / Avg. unit / lot value:
# of residential units / lots: / # of commercial units / lots: / Total # of units at build out:
(>500 units may require additional information)
# of owners in dues arrears over 90 days:
SECTION VII: Umbrella liability(offered outside package through Great American) Quote not requested (skip section)
Expiring carrier: / Limit: $ / Retention: $ / Premium: $
Requested limit: $ / Effective date:
- # of vehicles: Please complete supplemental application None
- Any incurred losses in excess of $100,000 under any primary liability policy in the last 5 years?
- Underlying carrier information
Commercial auto liability: / $1,000,000 / Combined single limit
Employer's liability: / $500,000
$500,000
$500,000 / Each accident
Each policy
Each employee
Garage keepers legal liability / $ 1,000,000 / Each occurrence / aggregate
Directors & offices liability not for profit community association*
(Only Great American, Travelers, USLI, Farmers, Liberty Mutual, C.N.A, CAU – monoline are acceptable underlying carriers) / $1,000,000
$1,000,000
$ 1,000,000
OR / Each claim (indemnity)
Each claim (defense)
Aggregate each association
$2,000,000
$2,000,000 / Each claim (defense inside the limit)
Aggregate each association
All primary insurers must have an A.M. Best rating of A- VI or better. However, we will provide coverage over employers liability placed with Certified State Funds, Paramount Insurance Company, Public Service Mutual Insurance Company or Pinnacol Assurance of CO.
By checking this boxI acknowledge that I have read the above and agree that all primary insurance either currently complies or will be placed and/or amended to be in compliance with the underlying requirements prior to binding the umbrella insurance.
SECTION VIII: Signature
Notice to applicants: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in Colorado, Ohio, Oregon, or Washington; in Virginia, insurance benefits may also be denied.)Notice to Colorado applicants: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds hall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to Ohio applicants: Any person with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oregon applicants: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which is a crime and may subject the persona to criminal and civil penalties.
Notice to Washington applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
It is understood and agreed that this policy does not apply to any D&O claim made against any insured based upon, arising out of, relating to, directly or indirectly resulting from or in consequence of, or in any way involving any wrongful act or any fact, matter, circumstance, situation, transaction, casualty, event or decision, known by the insured prior to the initial coverage date, which would indicate the probability of such claim being made. Please obtain a copy of the policy through your broker and read it carefully.
This application must be signed by the association’s property manager or by a member of the board of trustees of the association in order to bind coverage.
SIGNATURE: / TITLE: / DATE:
See supplemental application section below.
Lake / Pond SupplementalSECTION I: General area of lake/ pond
1.Surrounding terrain consists of:
2.
- Is the lake/pond fenced?
- Signs posted?
- Does the public have access to lake/pond area?
- Do houses surround the lake/pond area?
- Do houses have boat docks?
- Lake/ pond size in area:
SECTION II: Lake use
Canoes / Fishing / Paddle boats
Row boats / Sail boats / Swimming
Lifeguard on duty / Power boats*
*Maximum horse power and length allows: / Boat rentals? Yes NoTypes rented:
SECTION III: Association
- Adult only (no children permanently residing)?
- Family?
- Office complex?
- Master association?
- Does association have fenced or gated entrance?
- Is entire association fenced?
Enclose copy of lake rules.
Signature
Any person, who knowingly and with intent to defraud any insurance company or other person, files an application for insurance of state of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material hereto, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties.
By checking this box I agree that I have read this entire supplemental application and have, or will have reviewed the restriction herein with my client prior to binding coverage.
BROKER SIGNATURE: / DATE:
Illinois Notice Supplemental
Named insured:
Illinois Notice
Uninsured / Underinsured Motorists Coverage
Illinois law requires that we provide Uninsured Motorist coverage with a limit of liability equal to the statutory limit of $20,000 per person and (subject to the per person limit) $40,000 per accident. Uninsured Motorist coverage provides protection for persons insured thereunder who are legally entitled to recover damages from owners or operators of uninsured motor vehicles and hit-and-run motor vehicles because of bodily injury, sickness or disease, including death, resulting therefrom.