770 Lexington Avenue, 12th Floor
New York, NY 10065
(212) 546-1000
2015 VRM II Umbrella Application:
Client ID #
$10,000,000 / $25,000,000 / $50,000,000 / $75,000,000 / $100,000,000 / $200,000,000
1. / Named Insured:
2. / Mailing Address: (C/O, Street, City, State, Zip Code) C/O
, , ,
Street / City / State / Zip
3. / Effective Dates: / to
MM/DD/YYYY / MM/DD/YYYY
4. / Insured Property Location: (If multiple locations please attach spreadsheet)
, , ,
Street / City / State / Zip
5. / Total Number of Habitational Units: / Total Acres of Vacant Land:
Total Commercial Square Footage: / (If Mercantile|Retail, Include List of Tenants)
6. / Current Umbrella Program: / Limit: $
7. / Type of Building: / Condo / Co-Op / Rental / HOA
Office / Industrial / Warehouse / Retail
Vacant Land / Other (Explain)
8. / Construction Type: / Fire Resistive / Joisted Masonry / Frame
Non-Combustible / Masonry Non-Comb. / Other:
9. / Building Information: / Year Built: / Year(s) Renovated: Roof | Electrical | Boiler | Plumbing
Bldg. Sq./ft: / # of Stories: / % Occupied / %
10. / Protective / Life Safety Devices: / YES / NO / YES / NO
Emergency Lighting / Fire Alarm System
Exterior Fire Escapes / If yes, Central Station or Manual Pull?
Sprinkler System (FULL) / Standpipes
Sprinkler System (PARTIAL)
If Partial – Please Specify Location. / SprinkleredHallways | Stairwells | Lobby | Laundry | Boiler Rm. | Trash Compactor
Battery Operated Smoke Detectors / Illuminated Exit Signs
If yes, Common area and or Units? / TV Monitors
Battery Replacement Protocol / Enclosed Stairwells
Hard Wired Smoke Detectors / Elevator Recall (Fire Dept. Key Panel)
If yes, Common area and or Units? / Doorman
Two Exits Per Floor
11. / Does the Insured have any Operations other than real estate ownership or Management? / Yes / No
If yes, please describe:
12. / Does the insured have any contracting , construction, builders’ risk and / or developer operations? / Yes / No
13. / Has Certificate of Insurance been obtained from Comm. Tenants naming this insured as AdditionalInsured? Minimum Commercial General Liability Limit Required: $1MM Each Occurrence. / Yes / No
14. / Is there a garage on the premises? / Yes / No / If yes, managed by / Third Party / Self Managed
If third party, total square footage: ______ / Certificate obtained? Yes / No
15. / Are there any restaurants on the premises? / Yes / No
If yes, has Liquor Liability certificate been obtained? / Yes / No / Alcohol ≤ 30% of annual receipts? Yes No
16. / Which of the following best describes the building? / (If none, check here )
Government Subsidized / Low Income Housing / Student Housing / Assisted Living Facility
Self Managed / Vacant
17. / Which of the following are housed in this particular building? / (If none, check here )
Day Care Center / Nightclub / Playground / Tennis Court / Golf Course / Horseback Riding
Health Club / Marina / Enclosed Mall / # of Lakes or Ponds: Mileage of Private Roads:
18. / # of Swimming Pools: / Fenced/Gated / Yes / No / Diving Boards / Yes / No
Depth markings? Yes No / Self Locking Gate / Yes / No Posted Signs Yes No
19. / # of Owned Automobiles: / Are there any autos used to transport passengers? / Yes / No
If owned automobiles, please check appropriate type: Private Passenger Light Truck / Maintenance
20. / SCHEDULE OF UNDERLYING LIABILITY: Must Be Completed To Bind
Primary Liability (CARRIER MUST BE A- VII OR BETTER) Per Location if Multiple Locations.
Carrier:
Policy #: / Effective Date: / Expiration Date:
Per Occurrence Liability Limit: / General Aggregate:
Five Years of currently valued loss runs attached? / Yes / No
Provides a per location aggregate? / Yes / No
Does the underlying policy contain a Terrorism Exclusion? Yes No
Does the underlying policy include Employee Benefits Liability? Yes No
Directors and OfficersN/A (CARRIER MUST BE A- VII OR BETTER)
Carrier:
Policy #: / Effective Date: / Expiration Date:
Liability Limit:
Are Defense Costs Inside or Outside the Limit of Liability? / Inside / Outside
Have there been any D&O losses in the past 5 years? / Yes / No
Employers LiabilityN/A (CARRIER MUST BE A- VII OR BETTER)
Carrier:
Policy #: / Effective Date: / Expiration Date:
Liability Limit:
Number of Employees:
Automobile Liability N/A (CARRIER MUST BE A- VII OR BETTER)
Carrier:
Policy #: / Effective Date: / Expiration Date:
Liability Limit:
Garage Liability N/A (CARRIER MUST BE A- VII OR BETTER)
Carrier:Policy #: / Effective Date: / Expiration Date:
Liability Limit:
Garage Keepers Legal Liability N/A (CARRIER MUST BE A- VII OR BETTER)
Carrier:
Policy #: / Effective Date: / Expiration Date:
Liability Limit:
Inspection Contact: Phone Number:
FRAUD CLAUSE: Any person who knowingly and with intent to defraud any insurance company or 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 act, which is a crime.
Applicant / Authorized Representative Named & Signature:
Date:
May 8, 2015 Edition