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Directors & Officers Insurance Application

 

Type of coverage being requested: Community Association Professional Liability General Liability Property Umbrella Crime
Please fill out the General Information section, along with the section(s) you are requesting coverage.
 
GENERAL INFORMATION SECTION:
1. Association Name:
2. Mailing Address:
3. Location Address:
4. Website Address: Email Address:
5. Contact Name: Contact Phone Number
6. Name of Propetry Manager or Firm:
7. Association Type: Single Family Home Townhome Duplex/Twin Condominium Cooperative
Other(explain)
 8.Total Number of Units: Number of Employees:
 9. Date Organized: Date Final Unit Built:
 10. Any prior, existing or pending bankruptcy in the past five years? Yes No
 11. Does the association have an affiliation with, own or maintain the following:

a. Airport or Airstrip: Yes No
b. Golf Course: Yes No
c. Country Club for outside members: Yes No
d. Water Treatment Facility: Yes No
e. Sewer Treatment Facility: Yes No
f. Timeshare or interval Units: Yes No

 12. Does the builder, developer or sponsor maintain representation on the Board? Yes No
 
 
COMMUNITY ASSOCIATION PROFESSIONAL LIABILITY COVERAGE SECTION: 
13. Does the association have a positive fund balance? Yes No
14. Are over 70% of the units sold? Yes No
15. Are over 50% of the units rented/leased? Yes No
16. Does any person(s) or entity including, but not limited to the builder or developer, own multiple units comprising more than 10% of total number or units? Yes No
if "Yes", list the name(s) of the person(s) or entity and the percentage of units owned by each:
Name: %
Name: %
Name: %
17. Is the complex being built on a phase basis? Yes No
if "Yes", are at least 70% of the total number of units upon completion or all phases sold? Yes No
18. Does average unit value exceed $1,000,000? Yes No
19. Any commercial occupancy? (offices, restaurants, dry cleaner, etc) Yes No
20. Has any insurance policy in the name of the association ever been cancelled or non-renewed? Yes No
if "Yes", please explain details:

21. Within the psat 24 months:
a. Has the association completed a foreclosure sale against a unit owner? Yes No
b. Have any board elections been challenged? Yes No
c. Has the board taken legal action against a unit owner for reasons other than the collection
of dues or fees? Yes No
d. if "Yes" to any of the above, please provide details including unit owner name and date of event:

22. Within the last 5 years:
a. Have there been any countersuits as a result of liens or foreclosures? Yes No
b. Has any claim been made, is any claim being made, or is any claim now pending against the association, or any person proposed for insurance in the capacity of director, officer, trustee, employee, or volunteer of the
association? Yes No
c. Is any person proposed for this insurance aware of any fact, circumstance or situation which may result in a claim against the association, or any of its directors, officers, employees or volunteers? Yes No
d. If Yes, please advise details of the suit(s) or claim(s), including defense costs incurred, damages paid, whether it was covered by insurance and any remedial measures taken to prevent a recurrence of such claim(s) or suit(s).
 
GENERAL LIABILITY COVERAGE SECTION:
23. Have all planned units/homes been built? Yes No

Any planned construction/renovation of common facilities? Yes No
a. if Yes, please provide details including estimated date of completion.

24. Is the association responsible for maintenance or insurance for any residential buildings? Yes No

if Yes, please provide details:

25. Does the association own any vehicles or watercraft? Yes No
If Yes, type and use:

a.Does the association carry insurance for the vehicle or watercraft? Yes No
b. If Yes, please provide carrier and Limits:

c. Any rental of watercraft? Yes No
26. Hired and Non_Owned Auto Liability Check if coverage is desired.
if checked, answer a through c.

a. Does the applicant have a Business (or Commercial) Automobile Insurance Policy in force? Yes No
b. Does the applicant regularly deliver goods or products? Yes No
c. Does the applicant require its employees to use their personal automobile to conduct the applicant's business on a regular basis? Yes No

27, Is the association subject to any age-restrictive covenants? Yes No
28. Does the association obtain certificates of General Liability and Workers Compensation
coverage from all contractors? Yes No
29. Is there any use of association facilities by non-unit owners or the public? Yes No

a. if Yes, please provide details:

30. Are any organized sporting competitions or meets held on the premises? Yes No

 a. if Yes, please provide details:

31. Does the association sponsor any athletic teams? Yes No

 a. if Yes, please provide details:

32. Is there more than 20% exposure to student or subsidized renters?  Yes No

33. Is the association responsible for the maintenance of any streets/roads? Yes No

a. if Yes, number of miles
please describe

34. Is there a swimming pool/spa/jacuzzi on the premises? Yes No

Total number: Pools Spas Jacuzzis
How many separate locations?
a. Fully enclosed with self-latching gate? Yes No
b. Clear depth markers? Yes No
c. Life saving equipment in the pool area? Yes No
d. A sign clearly posted with rules? Yes No
e. Diving board or slides? Yes No

35. Is there a fitness center or fitness equipment on the premises? Yes No
a. Are there any services provided? Yes No
b. Please describe services provided:
36. Is there a lake or beach? Yes No

a. Owned/controlled by the association? Yes No
b. Total size of all lakes (acres)
c. Are there any dams or bridges Yes No
d. Is swimming permitted? Yes No

If Yes to d, (swimming allowed)
1. Any diving boards or slides Yes No
2. Are rules clearly posted? Yes No
3. Is life-saving equipment located within a resonable distance? Yes No
4. Is the beach or lake for use by the association only? Yes No

37. Is there a pier? Yes No

a. Are there any commercial operations on the pier? Yes No
b. Is there a fee or charge to access the pier? Yes No

38. Are there docks? Yes No
a. Owned by Applicant association: Yes No Individual Unit Owners: Yes No
Another association: Yes No
b. Number of slips:
c. Is docking of commercial vessels permitted? Yes No
d. Are any marina services provided (fueling, storage, repair or sales)? Yes No
39. Are there any playgrounds? Yes No
a. Total number:
b. Ground Surface:
c. Are signs posted requiring adult supervision? Yes No
40. Are there any walking/riding/bicycle trails? Yes No Number of Miles:
41. Are there sport courts? Yes No
a. Total number:
b. Type (check all that apply) Basketball Tennis Volleyball Shuffleboard Other
Explain "Other"
42. Total area of open space, parks and greenbelts (acres):
43. Does the association have an affiliation with, own or maintain the following? 

a. Animal Stables: Yes No
b. Armed Security Guards or Off-Duty Police: Yes No
c. Bridges for Vehicle Traffic: Yes No
d. Day Care: Yes No
e. Skiing or resort activities: Yes No
f. Fire/Police/Ambulance: Yes No
g. Electrical Generation or other utilities:  Yes No

44. Any General Liability losses in the past 3 years? Yes No
a. if Yes, please specify loss runs.
45. Any association-owned common buildings? (mail in answers for more than 2 buildings) Yes No
If more than 2 buildings how many? we will contact you about any buildings above 2
a. Building #1

1. Used for:
2. Construction:
3. Size (square feet)
4. Type of Roof:
Composition Shingle Flat Clay/Concrete Tile Slate Metal Wood Shingle/Shake
5. Age of Roof:
6. Functioning smoke detectors covering entire building? Yes No
7. Electrical service is 100% connected to functional circuit breakers? Yes No
8. Any aluminum or knob and tube wiring? Yes No
9. Sprinkler system? Yes No Full Partial
10 Any commercial cooking? Yes No

if Yes, please answer the following:

a. Is there a cleaning contract in force with an outside firm? Yes No
b. Describe Cooking equipment used: Grills Open Flame Oven
Deep Fat Fryers Charcoal Grill Barbeque Pit/Smoke
Type or Brand: Distance from building:
c. Are the cooking area, hood and duct system protected per NFPA 96 (Fire Extinguishing System)? Yes No
d. Type of Extinguishing system? Wet Dry

b. Building #2

1. Used for:
2. Construction:
3. Size (square feet)
4. Type of Roof:
Composition Shingle Flat Clay/Concrete Tile Slate Metal Wood Shingle/Shake
5. Age of Roof:
6. Functioning smoke detectors covering entire building? Yes No
7. Electrical service is 100% connected to functional circuit breakers? Yes No
8. Any aluminum or knob and tube wiring? Yes No
9. Sprinkler system? Yes No Full Partial
10 Any commercial cooking? Yes No

if Yes, please answer the following:

a. Is there a cleaning contract in force with an outside firm? Yes No
b. Describe Cooking equipment used: Grills Open Flame Oven
Deep Fat Fryers Charcoal Grill Barbeque Pit/Smoke
Type or Brand: Distance from building:
c. Are the cooking area, hood and duct system protected per NFPA 96 (Fire Extinguishing System)? Yes No
d. Type of Extinguishing system? Wet Dry

PROPERTY COVERAGE SECTION:
46. Any Property Losses in the past 3 years? Yes No
a. If Yes, please provide loss runs.
47. Protection Class:
48. Please provide 100% replacement cost value for any of the following association-owned property: 
a. Building #1: (Complete all parts of #45a)
b. Building #2: (Complete all parts of #45b)
c. Canopy/Awning:
d. Business Personal Property/Contents:
e. Fences/Walls/Gates/Entry Features:
f. Irrigation/Sprinkler System:
g. Lights/Poles:
h. Shed/Gazebo:
i. Signs:
j. Docks/Slips:
k. Sport Courts:
l. Playgrounds:
m. Pools/Spas/Jacuzzis:
n. Streets/Roadways:
o. Patios:
p. Walkways:
q. Trees/Shrubs:
r. Other paved surfaces (describe)
s. Outdoor Equipment:
t. Garage:
UMBRELLA COVERAGE SECTION:
49. Number of Stories:
50. Contstruction Type: Frame Joisted Masonry Masonry Non-Combustible Fire Resistive
51. Is 100% of the electrical service to the building/complex, including units, connected to circuit breakers? Yes No
52. Any aluminum or knob & tube wire present in the building/complex including units? Yes No
53. Is there a functioning sprinkler system in the building/complex? Yes No Full Partial
54.Are functioning and operational smoke detectors present in all common areas and units?  Yes No
55. Is there a fully-enclosed fire protected stairwell or a functioning fire escape?  Yes No
56. Is there more than 20% exposure to student or subsidized renters? Yes No
57.Any General Liability losses over $10,000 in the past 3 years? Yes No
If Yes, please give loss runs
58. Are all underlying carriers rated at least B++ by A.M.Best?   Yes No
59. Does the association own any automobiles? Yes No
a. If Yes, Please specify number and type
1. Private Passenger Vehicles
2. Light Truck (gross vehicle weight up to 10,000lbs) Number
3. Medium Trucks (gross vehicle weight 10,001 to 20,000) Number

b. Do any of the following exist:

1. Vehicles with an average daily radius of operation greater than 200 miles? Yes No
2. Vehicles EVER traveling a distance greater than 500 miles? Yes No
3. Heavy trucks or truck trailers, extra heavy trucks, or trucks tractors? Yes No
4. Emergency vehicles (Police, Ambulance, EMT, Fire/Rescue)? Yes No
5. Livery vehicles with seating for more than 26 passengers? Yes No
6. Any transportation of elderly, handicapped or non-emergency medical patients (para-transit or Non-emergency Ambulettes Yes No

c. Any drivers under 21 years of age? Yes No
d. Any drivers over 69 years of age? Yes No

1. if Yes, Does the applicant require and keep on file a Statement of Fitness for each driver signed by a physician? Yes No

e. Are the motor vehicle records (MVR) of every driver reviewed at least every 3 years? Yes No
 
General Liability
ISO Form Manuscript Form
A.M. Best Rating
Policy #
Effective Date
Limits of Liability

General Aggregate $
Products Aggregate $
Personal & Advertising Injury $
Occurrence $
Damage to Premises Rented $
Medical Payments $

 
Premium $
Auto Liability
A.M. Best Rating
Policy #
 Effective Date
C.S.L. $
Split Limits $ /$ /$
 Premium $
Employers Liability
A.M. Best Rating
Policy #
Effective Date
Bodily Injury by Accident (ea. accident) $
Bodily Injury by Disease (policy limit) $
Bodily Injury by Disease (ea. employee) $
COMMERCIAL CRIME COVERAGE (OPTIONAL)
All questions below must be answered and the application must be signed by the President or Chairperson ifCommercial Crime Coverage is desired. This section of the application is for a loss sustained policy.
Organization Background
60. Annual Association Revenue: current year: $ Number of years in operation:
61. Are there sources of income other than dues, assessments and investments? Yes No
if Yes, please explain:
62. Does the Organization have Crime Coverage? Yes No
63. Does the association have a property manager? Yes No
If Yes, does the property manager carry insurance for Employee Theft? Yes No Unknown
Limit of Liability $
If No, does the association segregate duties so no one person has access to or processes an entire transaction (e.g. check signing, payment and processing)? Yes No
Organization Operation Details
64. Does the association have an annual financial statement prepared? Yes No
65. Is a financial statement prepared by an outside accountant independant of the association and property manager (if any)? Yes No
66. Is the association's bank account(s) reconciled by someone other than the person also authorized to withdraw, deposit or transfer funds?   Yes No If Yes, How often? Quarterly Semi Annually Annually Other
67. What threshold amount on checks written by the association requires a countersignature? All None
Amount $
Claim Information: 
68. Within the past 5 years, have there been any incidents, occurrences or claims for theft, embezzlement, larceny, robbery, unlawful taking or other forms of dishonesty involving the proposed Named Insured or any person proposed for this insurance? Yes No
If Yes, advise below, the following for each claim: description of loss, date of loss, amount of loss, amount recovered (if any), name & position of person(s) involved, corrective action taken to prevent repetition, is the individual(s) involved in the theft, embezzlement, larceny, robbery, unlawful taking or other forms of dishonesty still involved in the affairs of the association in any capacity (as a board member, employee, committee person or other volunteer).
69. Is any person proposed for this Insurance aware of any fact, circumstance or situation that may give rise to a claim by the Named Insured proposed for this Insurance involving theft, embezzlement, larceny, robbery, unlawful taking or other forms of dishonesty involving the proposed Named Insured or any person proposed for this insurance? Yes No
If, Yes, please provide details
New York Disclosure Notice:This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, Most recent 12 month financial statement (if audited, submit full audit including auditor’s notes) occurrences or alleged wrongful acts that took place prior to the retroactive date, if any, stated on the declarations. This policy shall cover only those claims made against an insured while the policy remains in effect and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium increases independent overall rate increases until the claims-made relationship has matured.
Virginia Notice: You have an option to purchase a separate Limit of Liability for the extension period, policy common conditions I. If you do not elect this option, the Limit of Liability for the extension period shall be part of and not in addition to the limit specified in the declarations. Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company forthe purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or a napplication containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime.
Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material there to, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty ofinsurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States):Any person who knowingly presents a false or fraudulent claim fo rpayment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
 
Applicants Signature: Title: Date:
* If Crime Coverage is desired, application must be signed by the President or Chairperson.

If the primary address of the location listed in item #1 is in the state of New York, Iowa, or Florida, the states of New York, Iowa and Florida require that we have the name and address of your (insured’s) authorized Agent or Broker.
Name of Authorized Agent or Broker
Address:
City: State: Zip:
Agent or Broker License Number:
 

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