Umbrella Application for Community Associations Application.

Named Insured:

Mailing Address:

Location Address:

City

State

Zip

Type of Building:

Condo
Co-Op
Homeowners Assoc
PUD
Other

# of Units

# of Stories

Does the Association allow short-term or seasonal rental of units?

YesNo

Ownership & Control

Units are currently under construction

Completion Date

Developer

Additional Insured (Please provide name and relationship to the insured.)

Additional Operations under Insured Name (Describe)

# of Board Seats

# Held By Developer

Recreation Facilities (check all that apply): N/A

Community Room

Pools

Fenced

Lifeguards

Diving Boards

Self-locking gates

Exercise/Weight Room

Supervised Unsupervised

Playground equipment

Do you have any of the following (check all that apply): N/A

Saddle animals

Golf

Liquor sales other than host

Day/Child care

Airport/Landing strip/Airplane

Rent facilities to non-members

Watercraft

Sponsor off-premises events

Elder care/assisted living facilities

Lakes, private beaches, recreational ponds

Retention or other non-recreational pond

Access to Complex (check all that apply): N/A

Monitored by Security Personnel

Key Card entry

Doorman

Armed Guards

Gates controlled by residents

Do the buildings contain any of the following (check all that apply): N/A

Offices rented to others

Restaurants

Retail Stores

Delicatessens/Grocery/Convenience Stores

Other businesses

Hours of operations

Building Information

% Occupied

Year Built

Underlying Carrier Information
All Underlying carriers must be rated A- (VI) or higher

General Liability

Limits		Company	A.M. Best Rating	Exp. Date	Policy Number

Workers Compensation

Limits		Company	A.M. Best Rating	Exp. Date	Policy Number
Auto

Limits	Liability Auto Symbol	Company	A.M. Best Rating	Exp. Date	Policy Number
D&O

Limits		Company	A.M. Best Rating	Exp. Date	Policy Number

Special Considerations:

# of vehicles

(If any, please complete a supplemental automobile application)

None

Are General Liability defense costs outside the limits of liability?

YesNo

Is there special exclusionary wording or manuscript endorsements on any of the underlying policies? (If yes, Please provide copies of endorsements and/or wording.)

YesNo

Have there been any class action, title or construction defect (including indoor air quality) claims?

YesNo

Have there been any incurred losses in excess of $20,000, either reserved or paid, under any primary policy in the past five years? (If yes, please provide five years of hard copy loss runs.)

YesNo

Have there been incurred aggregate losses of $50,000 or more, in the past five years? (If yes, please provide five years of hard copy loss runs.)

YesNo

Limit requested

Effective Date

Agent/Broker Information
Agent/Broker Name	(Cannot contain: \ / : * ? " < > \|)
Address
City
State
Zip
Phone
Fax
E-mail

NOTICE
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURANCE COMPANY OR OTHER PERSON FILES THIS QUESTIONNAIRE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND WHICH MAY RESULT IN CIVIL OR CRIMINAL FINES OR PENALTIES.

By checking this box the sender agrees with the above notice.

The Distinguished Program Group

1180 Avenue of the Americas 16th fl, New York, NY 10036

1-212-297-3100