Insurance Community Renewal Applications

INSURANCE COMMUNITY RENEWAL APPLICATION

Applicant / Insured Information

Applicant Name:

Individual Corporation Association / HOA Other:

Date of Birth (if individual) or FEIN (if entity):

Community Details

Construction Type:   Stories:

Average Unit Size (sq ft):   Occupancy Type:

Swimming Pool on Premises:   Number of Elevators:

Sprinkler System Installed:   If yes, percent of area sprinklered: %

Fire Alarm System:   Central Station Monitoring:

Current Policy Details

Policy Number:   Policy Period From:  To:

Property General Liability Directors & Officers Fidelity / Crime Flood Excess / Umbrella

Annual Premium:

Requested Renewal Coverage

Property General Liability Directors & Officers Fidelity / Crime Flood Excess / Umbrella

Requested Deductible:   Desired Effective Date:

Loss History (Past 5 Years)

Has the community had any claims, incidents or losses in the past five years?   Yes    No

If yes, provide details for up to three losses. Attach additional pages if necessary.

Date of Loss:   Type:   Amount Paid:   Status:

Date of Loss:   Type:   Amount Paid:   Status:

Date of Loss:   Type:   Amount Paid:   Status:

Risk Management / Maintenance

On-site Manager Present:   24-hour Security Patrol:

Regular Preventive Maintenance Program:   Third-Party Management Company:

Exclusions and Important Conditions

The policy offered on renewal will include standard community association exclusions including, without limitation: intentional acts of insured parties, war and nuclear hazard, wear and tear, flood and earthquake (unless specifically scheduled), pollution unless endorsed, punitive damages where unenforceable by law, and loss or liability arising from misrepresentation on this application. Additional specific endorsements may apply based on underwriting review.

The undersigned acknowledges that coverage is subject to the full terms, conditions, exclusions and limits contained in the policy forms and endorsements issued. The insurer reserves the right to require additional information, inspections, or risk control measures as a condition of renewal.

Acknowledgement: I acknowledge and agree to the limitations and exclusions described above and certify that all material information has been provided.

Beneficiary / Payee Designation

Primary Payee Name:

Relationship to Insured:   Percentage of Proceeds: %

Certification and Authorization

The undersigned declares that the information contained in this application is true, complete and correct to the best of their knowledge. The undersigned understands that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage, rescission of the policy, or other remedies permitted by law.

The undersigned authorizes any current or prior insurer, insurance support organization, or other persons or organizations to release loss history, claims information, inspection reports, and other records necessary for underwriting and renewal evaluation. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

The applicant agrees to provide any requested supporting documentation including recent financials, minutes of association meetings where material exposures are discussed, proof of maintenance, and loss runs prior to binding coverage.

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