Crime for Community Associations Application.

If you are already joining our D&O Program, why not place your crime coverage with us as well? Just answer a few questions, decide on what limits you want and we will provide you a quote along with your D&O proposal.

 

Insuring Agreements: #1 Employee Dishonesty
#2 Forgery or Alteration
#3 Inside the Premises
#4 Outside the Premises
#5 Computer Fraud
 
Endorsements: Managing Agent
Employee Benefit Plans (when named)

Non-Compensated Officers and Members of the Board of Directors as Employer, Volunteers as Employer
 
Association Name:
Physical Address:
City:
State:
Zip:
Property Manager Company:
Mailing Address:
City:
State:
Zip:
Policy Effective Date:
Pension Plan Name (if any):
 
Yes No
Is the association crime claims-free for the last five years?
Are 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.
Are persons authorized to fire or hire association employees prohibited from distributing payroll?
If there is no payroll, click N/A.  N/A
Are bank accounts and credit card statements reconciled monthly by someone not authorized deposit, withdraw or initiate electronic funds transfers?
If No, please explain. 
Are volunteers (other than D&O's) prohibited from handling bank accounts or fee/mortgage payments?
If there are no volunteers, check here.
 
Choose Limit and Deductible
Limit Deductible Ins. Agreement #1 Ins. Agreement #1-5
$50,000 $1,000 $310  $486 
$100,000 $1,000 $459  $716 
$150,000 $1,000 $517  $808 
$200,000 $1,000 $572  $894 
$250,000 $2,500 $582  $904 
   
 
 
Agent/Broker Information
Agent/Broker Name
Address
City
State
Zip
Phone
Fax
E-mail
 
NOTICE:
THE POLICY FOR WHICH THIS QUESTIONNAIRE IS SUBMITTED IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE, AND REPORTED IN WRITING TO THE INSURER PURSUANT TO THE TERMS THEREIN. THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED AND MAY BE TOTALLY EXHAUSTED BY AMOUNTS INCURRED AS DEFENSE COSTS. PLEASE OBTAIN A COPY OF THE POLICY THROUGH YOUR BROKER AND READ IT CAREFULLY.

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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