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| Low Limits Umbrella for Community
Associations
AVAILABLE TO BUYERS OF OUR D&O LIABILITY POLICY ONLY
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| Named Insured: |
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| Mailing Address: |
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| Location Address: |
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| City |
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| State |
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| Zip |
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| Type of Building: |
Condo
Co-Op
Homeowners
Assoc
PUD
Other
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| # of Units |
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| # of Stories |
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| Does the Association allow short-term or
seasonal rental of units? |
Yes
No |
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| Ownership & Control |
| Units are currently under construction |
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| Completion Date |
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| Developer |
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| Additional Insured (Please provide name and
relationship to the insured.) |
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| Additional Operations under Insured Name
(Describe) |
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| # of Board Seats |
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| # Held By Developer |
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| Recreation Facilities
(check all that apply): N/A |
| Community Room |
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| Pools |
# |
| Fenced |
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| Lifeguards |
# |
| Diving Boards |
# |
| Self-locking gates |
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| Exercise/Weight Room |
Supervised
Unsupervised |
| Playground equipment |
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| Do you have any of the
following (check all that apply): N/A |
| Saddle animals |
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| Golf |
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| Liquor sales other than host |
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| Day/Child care |
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| Airport/Landing strip/Airplane |
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| Rent facilities to non-members |
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| Watercraft |
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| Sponsor off-premises events |
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| Elder care/assisted living facilities |
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| Lakes, private beaches, recreational ponds |
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| Retention or other non-recreational pond |
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| Access to Complex (check
all that apply): N/A |
| Monitored by Security Personnel |
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| Key Card entry |
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| Doorman |
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| Armed Guards |
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| Gates controlled by residents |
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| Do the buildings contain
any of the following (check all that apply): N/A |
| Offices rented to others |
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| Restaurants |
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| Retail Stores |
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| Delicatessens/Grocery/Convenience Stores |
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| Other businesses |
Hours of operations |
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| Building Information |
| % Occupied |
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| Year Built |
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Underlying Carrier
Information
All Underlying carriers must be rated A- (VI) or
higher
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| Special Considerations: |
| # of vehicles |
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| (If any, please complete a
supplemental automobile application) |
| None |
| Are
General Liability defense costs outside the limits of
liability? |
| Yes
No |
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| Is there special exclusionary
wording or manuscript endorsements on any of the underlying
policies? (If yes, Please provide copies of
endorsements and/or wording.) |
| Yes
No |
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| Have there been any class action,
title or construction defect (including indoor air quality)
claims? |
| Yes
No |
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| 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.) |
| Yes
No |
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| 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.) |
| Yes
No |
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| Limit requested |
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| Effective Date |
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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.
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