Directors and Officers Liability 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.

 

Agent/Broker Email
Agent/Broker Name
Name of Agency/Brokerage
Address
City
State
Zip
Phone
Fax
Current Date
 
Yes No
Have there been any D&O claims made against the Association in the last five years?
Is this the first time the Association has purchased D & O Insurance?
Has the Association's current D & O policy been cancelled or non-renewed by the carrier? (NOT APPLICABLE TO MISSOURI APPLICANTS.)
Does the Association anticipate any major building/renovations in the next year?
Is the Association controlled by the Developer?
 
Association Name:
Mailing Address:
Street Address:
City
State:
Zip:
Location Address:
City
State:
Zip:
How is association managed? 3rd Party Mgmt Co.
Employee(s) of the Association
Not Managed Professionally
Prop. Mgmt. Company:
Expiring: Carrier
Limit
Retention
Premium
Requested: GAIC                              Carrier
Limit
Retention
Premium
Effective Date:
Association Type:
% of units/lots sold: 
Total # of units/lots:
# of Commercial units/lots:
# of units in dues arrears over 90 days:
Avg. unit/lot value:
# of employees:
(0-9 employees are eligible)
# of Builder/Developer controlled board seats:
The following information is required of co-op, commercial, time share and property owners:
Total Assets:
Annual Salary Expense:
 
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.

IT IS UNDERSTOOD AND AGREED THAT THIS POLICY DOES NOT APPLY TO ANY 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 ANY INSURED PERSON PRIOR TO THE INITIAL COVERAGE DATE WHICH WOULD INDICATE THE PROBABILITY OF SUCH CLAIM BEING MADE. IT IS UNDERSTOOD AND AGREED THAT COVERAGE SHALL NOT BE EXCLUDED AS A RESULT OF ANY UNTRUE STATEMENT ON THIS APPLICATION, EXCEPT AS TO THE ORGANIZATION, ITS SUBSIDIARIES AND THOSE INSURED PERSONS HAVING SUCH KNOWLEDGE. 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.

 Send me a copy of the application via email.

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